Time-of-day and appendicitis: Impact on management and outcomes

Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization

INTRODUCTION

Appendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited.

METHODS

Patient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions.

RESULTS

Nine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups.

CONCLUSIONS

We found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.

Demonstration of a new entity of non-perforated appendicitis through studying cluster of appendicitis

Differential diagnosis and management for perforated appendicitis and non-perforated appendicitis are current hot topics. The aim of this study is to demonstrate a new entity of non-perforated appendicitis, “acute hemorrhagic appendicitis” through studying cluster of acute appendicitis among Tibetan students at a high school in central China. Over the 11-year period, there were 120 patients with more female patients (102 of 499, 20.4%) than male patients (18 of 474, 3.8%) among 973 Tibetan students. 117 patients’ clinical data were available. Clinical manifestations were identical to classic appendicitis. However, axilla temperature, white blood cell counts and neutrophil level were elevated mildly in 12 (10.3%), 19 (16.2%) and 12 (10.3%) patients respectively. Pathologically, the resected appendices exhibited focal or diffuse hemorrhages in mucosa and/or submucosa, and infiltration by eosinophil and by lymphocytes. No patients had perforated appendicitis. The median time from the onset to surgery was 3 days (IQR, 2–4). All patients were discharged with full recovery. In conclusion, “acute hemorrhagic appendicitis” represented a new entity of non-perforated appendicitis with unique cause and pathogenesis, which might be treated with antibiotics alone or self-limited. Studying the cluster is a reliable method to find new entity of appendicitis.

Daytime versus Nighttime in Acute Appendicitis

Background: Little is known about patients with appendicitis presenting at nighttime. It is hypothesized that patients presented at night more frequently have a complicated (gangrenous or perforated) appendicitis and therefore develop more postoperative complications. Methods: In this study data were used from the nationwide, prospective SNAPSHOT study appendicitis, including 1975 patients undergoing surgery for suspected appendicitis. This study included only adults. Two primary outcomes were defined: (A) The proportion of patients with complicated appendicitis and (B) the proportion of patients with a complication postoperatively presenting during daytime versus nighttime period. Analysis for both complicated and uncomplicated appendicitis was performed, and a multivariate model was used to correct for baseline characteristics and time to surgery. Results: In total, 1361 adult patients with appendicitis were analyzed. Both at nighttime and at daytime, 34% had complicated appendicitis. In patients presenting in the daytime, 12.1% developed a postoperative complication versus 18.6% for presentation at night (p = 0.008). In a multivariate analysis, the risk for a postoperative complication when presenting at night was significantly increased (adjusted OR 1.74; 95% CI 1.14–2.66, p = 0.01). Surgery within eight hours after presentation does not lower this risk (adjusted OR 1.37; 95% CI 0.97–1.95, p = 0.078). Conclusion: Complicated appendicitis is seen as frequently during the day as at nighttime. For patients who present at nighttime with acute appendicitis, the risk of a postoperative complication is higher compared with a presentation at daytime. In multivariate analysis, nighttime presentation but not surgery within 8 h after presentation is independently associated with postoperative complication risk.

Associations between surgical start time (regular vs after hours) and morbidity and mortality during hospitalization in dogs and cats

OBJECTIVE

To examine the relationship between after-hours (ie, nights and weekends) emergency general surgery and morbidity or mortality in dogs and cats during hospitalization.

DESIGN

Cross-sectional study from September 1, 2013 to May 31, 2017.

SETTING

University teaching hospital.

ANIMALS

Four hundred seventy-four dogs and 66 cats that underwent emergency general surgery (gastrointestinal, hepatobiliary, urogenital, soft tissue traumatic injury, splenectomy/excision of bleeding abdominal tumor, surgical revision, and negative exploratory categories) with the emergency surgery service. All patients were required to have complete medical records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Study animals were grouped as exposed or not exposed to after-hours emergency surgery. They were further classified as either postoperatively dead or suffering morbidity (yes or no). Additional exposure factors (eg, age, sex, American Society of Anesthesiology [ASA] status) were investigated. Multivariable logistic regression was used to identify and quantify any associations with mortality or morbidity. In dogs, exposure to after-hours emergency general surgery was not associated with mortality or morbidity. In dogs, both mortality and morbidity were associated with ASA status. In cats, mortality was not examined because the number of dead cats was small (n = 5). The odds of morbidity were 3.4 times lower (1/0.29) in cats having emergency surgery after hours, compared to cats admitted during regular hours (odds ratio [OR], 0.29; 95% Confidence Interval (CI), 0.09-0.93; P = 0.03). No other investigated exposure factors were associated with morbidity in study cats.

CONCLUSIONS

After-hours emergency surgery in dogs was not associated with increased risk of mortality and morbidity at the study facility. Feline patients having emergency surgery during regular hospital hours had a higher risk of morbidity; further investigation of modifiable risk factors is warranted.

Timeliness of pediatric surgical appendicitis care is associated with time of hospital admission

BACKGROUND

Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes.

METHODS

We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation.

RESULTS

During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates.

CONCLUSION

As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.

Context is Key: Using the Audit Log to Capture Contextual Factors Affecting Stroke Care Processes

High quality patient care through timely, precise and efficacious management depends not only on the clinical presentation of a patient, but the context of the care environment to which they present. Understanding and improving factors that affect streamlined workflow, such as provider or department busyness or experience, are essential to improving these care processes, but have been difficult to measure with traditional approaches and clinical data sources. In this exploratory data analysis, we aim to determine whether such contextual factors can be captured for important clinical processes by taking advantage of non-traditional data sources like EHR audit logs which passively track the electronic behavior of clinical teams. Our results illustrate the potential of defining multiple measures of contextual factors and their correlation with key care processes. We illustrate this using thrombolytic (tPA) treatment for ischemic stroke as an example process, but the measurement approaches can be generalized to multiple scenarios.

Reducing the negative appendectomy rate with the laparoscopic appendicitis score; a multicenter prospective cohort and validation study

BACKGROUND

Approximately nine percent of all acute appendectomies are unintentionally performed on a normal appendix. Failure of treatment (negative appendectomy or missed appendicitis) is associated with higher morbidity and mortality when compared to appendectomy for uncomplicated appendicitis. The Laparoscopic APPendicitis (LAPP) score was developed in order to systematically evaluate the appendix for the presence of inflammation. This study aims to determine whether the LAPP score reduces the negative appendectomy rate without missing appendicitis.

METHODS

From September 2013 through May 2016, 322 adult patients presenting with a clinical suspicion of acute appendicitis and an indication for diagnostic laparoscopy were included and analyzed in this multicenter prospective validation study. Depending on the LAPP score, the appendix was either removed (n = 300) or left in situ (n = 22). These patients were compared to a historical control group of 584 patients treated at the same hospitals. The appendix was examined by a pathologist and the negative appendectomy rate was calculated.

RESULTS

The negative appendectomy rate was significantly lower when the LAPP score was used (4,7% vs. 8,4%; P = 0,034). None of the patients with a negative LAPP score, in which the appendix remained in situ, developed acute appendicitis within three months. There were no significant differences in operation time, complications, or readmissions. Using the LAPP score was associated with significantly higher rates of preoperative radiological imaging (98% vs. 70%; P < 0,001). After adjusting for covariables, including radiological imaging, use of the LAPP score led to fewer treatment failures when compared to not using the LAPP score (OR: 0,48, 95% C.I. 0,251 to 0,914; P = 0,025).

CONCLUSION

The LAPP score is a safe and simple tool to reduce the negative appendectomy rate during laparoscopic surgery without missing cases of acute appendicitis.

The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies

Background Acute care surgery (ACS) models address high volumes of emergency general surgery and emergency room (ER) overcrowding. The impact of ACS service model implementation on the quality and efficiency of care (EOC) outcomes in acute appendicitis (AA) and acute cholecystitis (AC) cohorts was evaluated. Methods A retrospective chart review (N=1,229) of adult AA and AC patients admitted prior to (pre-ACS; n=507; three hospitals; 2007) and after regionalization (R-ACS; n=722; one hospital; 2011). Results R-ACS time to ER physician assessment was significantly longer for AA (3.4 ± 2.3 versus 2.4 ± 2.6 hr; p ≤ 0.001). Surgical response times (1.3 ± 1.2 vs 2.6 ± 4.3 hr for AA; 1.8 ± 1.5 vs 4.1 ± 5.0 hr for AC; p ≤ 0.0001) and acquisition of imaging (4.1 ± 4.1 vs 6.9 ± 9.9 hr for AA, p ≤ 0.0001; 7.8 ± 1.9 vs 13.2 ± 18.5 hr for AC, p ≤ 0.008) occurred significantly faster with R-ACS. R-ACS resulted in a significant increase in night-time appendectomies (21.7% vs 11.1%; p ≤ 0.002), perforated appendices (29.1 % vs 18.9 %; p ≤ 0.006), 30-day readmissions (4.56% vs 0.82%; p ≤ 0.01), and lower rate of intraoperative complications for AC patients (2.78% vs 7.69%; p ≤ 0.02). Conclusions Despite the increased volume of patients seen with the implementation of R-ACS, surgical assessments and diagnostic imaging were significantly more prompt. EOC measures were maintained. Worse AA outcomes highlight areas for improvement in delivering R-ACS.

Emergency department patient experience: Same location, same provider, different scores by different survey methods

BACKGROUND

Recent findings on emergency department (ED) patient experience surveys and concerns for the low response rates challenge the quality and reliability of the survey reports. We assessed the consistency of an ED patient experience survey report and identified the effects of patient demographics on ED patient experiences.

METHODS

We conducted a prospective, cross-sectional study at a university-based ED from July to December 2017. We obtained ED patient experience scores from an institutional version (IS) survey and the Press Ganey Associates-distributed survey (PGA). We compared top box scores from the two reports using frequency analysis and performed multivariable logistic regressions to identify associations between IS patient demographics and scores.

RESULTS

We obtained 289 PGA and 234 IS responses. The IS reported significant, higher top box scores in doctor-specific patient questions compared to PGA (all four P-values < 0.01). Female, Christian and White patients were more likely to give top box scores (OR 3.07, OR 2.22 and OR 2.41, P-value < 0.05, respectively).

CONCLUSION

We found significant differences in ED patient experience scores between the IS and PGA surveys. We recommend that healthcare providers consider patient demographic variables when interpreting ED experience score reports. Multiple survey techniques and distribution methods may be adopted to best capture ED patient experiences.

A protocol for non-operative management of uncomplicated appendicitis

BACKGROUND

We developed a protocol to identify candidates for non-operative management (NOM) of uncomplicated appendicitis. Our objective was to evaluate protocol efficacy with the null hypothesis that clinical outcomes, hospital readmission rates, and hospital charges would be unchanged after protocol implementation.

METHODS

We performed a single-center 4-year propensity score matched retrospective cohort analysis of 406 patients with acute uncomplicated appendicitis. The protocol recommended NOM for patients with modified Alvarado score ≤6 and no appendicolith. Patients admitted before (n = 203) and after (n = 203) protocol implementation were matched by Charlson comorbidity index, duration of symptoms, and modified Alvarado score. Outcomes included operative management, days on antibiotic therapy, length of stay, and hospital charges, as well as readmissions, complications, and mortality within 180 days.

RESULTS

Baseline characteristics were similar between groups (age 31 years, ASA class 2.0, Charlson comorbidity index 0.0). Protocol compliance was higher when the protocol recommended appendectomy (97%) rather than NOM (73%, p < 0.001). The incidence of operative management decreased from 99% to 82% after protocol implementation (p < 0.001). In the protocol group, there was a lower incidence of open surgery (4% vs. 10%, p = 0.044) despite a longer interval between admission and surgery (8.6 vs. 7.1 hours, p < 0.001). After protocol implementation, 51 patients had NOM: 18 failed NOM during admission and 6 failed NOM after discharge. Compared to the pre-protocol group, the protocol group had similar length of stay, antibiotic days, and overall complication rates, but more readmissions (6% vs. 1%, p = 0.019) and lower hospital charges for the index admission ($5,630 vs. $6,878, p < 0.001).

CONCLUSIONS

Implementation of a protocol to identify candidates for NOM of acute uncomplicated appendicitis was associated with lower rates of open surgery, fewer appendectomies, decreased hospital charges, and no difference in overall complications despite high rates of readmission and failure of NOM.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Outpatient Appendectomy in an Emergency Outpatient Surgery Unit 24 h a Day: An Intention-to-Treat Analysis of 194 Patients

OBJECTIVE

To evaluate the feasibility and outcomes of patients operated on for uncomplicated acute appendicitis (UAA) in our 24-h emergency outpatient surgery unit.

METHODS

This was a prospective observational study with intention-to-treat (ITT) analysis. From 12/2013 to 03/2015, all consecutive patients admitted for acute appendicitis (AA) were prospectively screened. A computed tomography or abdominal ultrasound confirmed the diagnosis of AA. Eligibility criteria for outpatient appendectomy were: UAA, no comorbidity, no physical or mental condition preventing participation in the study, absence of pregnancy, age older than 15 years, an accompanying adult person available for the hospital discharge and place of residence within 1 h of our hospital. In the case of intraoperative complication (abscess, local or general peritonitis) or complication of general anesthesia, patients were excluded from the outpatient pathway. The primary endpoint was the feasibility of outpatient appendectomy among all consecutive patients admitted for UAA.

RESULTS

Of the 194 screened patients, 150 (77%) presented an UAA and 102 (68%) were eligible for an outpatient procedure. Thirteen eligible patients (13%) were excluded from the outpatient circuit (7 intraoperative and 6 postoperative contraindications). Outpatient appendectomy was performed in 89 patients, representing 59% (89/150) of the ITT population and 87% (89/102) of the eligible patients. The median length of hospital stay was 13 h. Postoperative complications were observed in six patients (6%).

CONCLUSIONS

This study reports a safe and feasible management of UAA. Our organization allows a short hospitalization for postoperative recovery without using conventional surgery beds and enables discharge throughout the night.

Pediatric appendicitis: state of the art review

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.