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Sylivris A, Ramson DM, Penny-Dimri JC, Liu Z, Perry LA, Au J, Yang Z, Park B, Pitesa R, Singh S, Smith JA, Taneja A, Eglinton T, Welsh F, Koea J, MacCormick AD, Barazanchi A, Hill AG. Weekend effect in emergency laparotomy: a propensity score-matched analysis. ANZ J Surg 2023; 93:1806-1810. [PMID: 37420316 DOI: 10.1111/ans.18595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. METHODS A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics. RESULTS Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). CONCLUSIONS These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.
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Affiliation(s)
- Amy Sylivris
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Dhruvesh M Ramson
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | | | - Zhengyang Liu
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Luke A Perry
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jessica Au
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Zoe Yang
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Brittany Park
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - Renato Pitesa
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - Surya Singh
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - Julian A Smith
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Ashish Taneja
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Tim Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Fraser Welsh
- Department of General Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Jonathan Koea
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
| | - Andrew D MacCormick
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - Ahmed Barazanchi
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, Middlemore Hospital, University of Auckland, Auckland, New Zealand
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Tebala GD, Milani MS, Cirocchi R, Bignell M, Bond-Smith G, Lewis C, Agnoletti V, Catarci M, Di Saverio S, Luridiana G, Catena F, Scatizzi M, Marini P. The weekend effect on the provision of Emergency Surgery before and during the COVID-19 pandemic: case-control analysis of a retrospective multicentre database. World J Emerg Surg 2022; 17:22. [PMID: 35488247 PMCID: PMC9051756 DOI: 10.1186/s13017-022-00425-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/22/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction The concept of “weekend effect”, that is, substandard healthcare during weekends, has never been fully demonstrated, and the different outcomes of emergency surgical patients admitted during weekends may be due to different conditions at admission and/or different therapeutic approaches. Aim of this international audit was to identify any change of pattern of emergency surgical admissions and treatments during weekends. Furthermore, we aimed at investigating the impact of the COVID-19 pandemic on the alleged “weekend effect”.
Methods The database of the CovidICE-International Study was interrogated, and 6263 patients were selected for analysis. Non-trauma, 18+ yo patients admitted to 45 emergency surgery units in Europe in the months of March–April 2019 and March–April 2020 were included. Demographic and clinical data were anonymised by the referring centre and centrally collected and analysed with a statistical package. This study was endorsed by the Association of Italian Hospital Surgeons (ACOI) and the World Society of Emergency Surgery (WSES).
Results Three-quarters of patients have been admitted during workdays and only 25.7% during weekends. There was no difference in the distribution of gender, age, ASA class and diagnosis during weekends with respect to workdays. The first wave of the COVID pandemic caused a one-third reduction of emergency surgical admission both during workdays and weekends but did not change the relation between workdays and weekends. The treatment was more often surgical for patients admitted during weekends, with no difference between 2019 and 2020, and procedures were more often performed by open surgery. However, patients admitted during weekends had a threefold increased risk of laparoscopy-to-laparotomy conversion (1% vs. 3.4%). Hospital stay was longer in patients admitted during weekends, but those patients had a lower risk of readmission. There was no difference of the rate of rescue surgery between weekends and workdays. Subgroup analysis revealed that interventional procedures for hot gallbladder were less frequently performed on patients admitted during weekends. Conclusions Our analysis revealed that demographic and clinical profiles of patients admitted during weekends do not differ significantly from workdays, but the therapeutic strategy may be different probably due to lack of availability of services and skillsets during weekends. The first wave of the COVID-19 pandemic did not impact on this difference.
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Affiliation(s)
- Giovanni D Tebala
- Surgical Emergency Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. .,Digestive and Emergency Surgery Unit, Azienda Ospedaliera "S.Maria", "S.Maria" Hospital, Viale Tristano di Joannuccio, 05100, Terni, Italy.
| | - Marika S Milani
- Department of General Surgery, Causa Pia Luvini Hospital, Cittiglio, Italy
| | - Roberto Cirocchi
- Digestive and Emergency Surgery Unit, Azienda Ospedaliera "S.Maria", "S.Maria" Hospital, Viale Tristano di Joannuccio, 05100, Terni, Italy
| | - Mark Bignell
- Surgical Emergency Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Giles Bond-Smith
- Surgical Emergency Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Lewis
- Surgical Emergency Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vanni Agnoletti
- Department of Anaesthesia and Intensive Care, "M. Bufalini" Hospital, Cesena, Italy
| | - Marco Catarci
- Department of General Surgery, "S. Pertini" Hospital, Rome, Italy
| | - Salomone Di Saverio
- Department of General Surgery, Madonna del Soccorso Hospital, S.Benedetto del Tronto, Italy
| | | | - Fausto Catena
- Department of General and Emergency Surgery, "M. Bufalini" Hospital, Cesena, Italy
| | - Marco Scatizzi
- Department of General Surgery, S.Maria Annunziata Hospital, Florence, Italy
| | - Pierluigi Marini
- Department of General and Emergency Surgery, S.Camillo-Forlanini Hospital, Rome, Italy
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3
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Patel MS, Thomas JJ, Aguayo X, Gutmann D, Sarwary SH, Wain M. The Effect of Weekend Surgery on Outcomes of Emergency Laparotomy: Experience at a High Volume District General Hospital. Cureus 2022; 14:e23537. [PMID: 35494929 PMCID: PMC9041642 DOI: 10.7759/cureus.23537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/05/2022] Open
Abstract
Aims Emergency laparotomies (ELs) are associated with significant morbidity and mortality. Delays to the theater are inevitably associated with worse outcomes. Higher mortality has been reported with admissions over the weekend. The aim of this study is to compare the delays and outcomes of emergency laparotomies performed on weekdays (WD) and weekends (WE) at a high-volume, large district general hospital. Methods A retrospective review of a prospectively maintained database was performed for all patients who underwent general surgical emergency laparotomy between June and October 2021. Patient outcomes were compared between delayed and non-delayed surgeries as per the NCEPOD (National Confidential Enquiry into Patient Outcomes and Death) classification. The primary outcome compared was the 30-day post-operative mortality and morbidity determined by the Clavein-Dindo class ≥2. Secondary outcomes included the time from booking to anaesthesia start time, i.e., time to theatre (TTT), delay in surgery, out-of-hours (OOH) surgery, and unplanned return to theatres. Results Of the 103 laparotomies included, 33% were performed over the weekend. The most common indication for emergency laparotomy was bowel obstruction (53.4 %), followed by perforation (28.2%). There was no significant difference in mortality, the TTT (p = 0.218), delay in surgery with respect to the NCEPOD category of intervention (p = 0.401), postoperative length of stay (p = 0.555), number of cases operated OOH as well as unplanned return to theatres. There was a significant difference in the morbidity of patients between the two groups (Clavein-Dindo class ≥2, p = 0.021). Conclusion With consistent consultant involvement, an equivalent standard of weekend emergency surgical service can be delivered.
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Anger F, Lichthardt S, Haubitz I, Wagner J, Löb S, Buhr HJ, Germer CT, Wiegering A. Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registry. PLoS One 2022; 17:e0277050. [PMID: 36327244 PMCID: PMC9632786 DOI: 10.1371/journal.pone.0277050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Higher postoperative mortality has been observed among patients who received emergency colorectal surgery on the weekend compared to during the week. The aim of this study was to determine whether the weekday of emergency surgery affects the 30-day mortality and postoperative course in emergency colorectal surgery. METHODS Prospectively acquired data from the 2010-2017 German StuDoQ|Colorectal surgery registries were analysed. Differences in 30-day mortality, transfer and length of stay (MTL30) (primary endpoints), postoperative complications, length of stay and pathological results of resected specimens (secondary endpoints) were assessed. Multivariable analysis was performed to identify independent risk factors for postoperative outcome. RESULTS In total, 1,174 patients were included in the analysis. Major postoperative complications and the need for reoperation were observed more frequently for emergency colorectal surgery performed during the week compared to the weekend (23.01 vs. 15.28%, p = 0.036 and 17.96% vs. 11.11%, p = 0.040, respectively). In contrast, patients who received emergency surgery on the weekend presented with significantly higher UICC tumour stages (UICC III 44.06 vs. 34.15%, p = 0.020) compared to patients with emergency colorectal surgery on a weekday. Emergency surgery performed during the week was an independent risk factor for the development of severe postoperative complications (OR 1.69 [1.04-2.74], p = 0.033) and need for reoperation (OR 1.79 [1.02-3.05], p = 0.041) in the multivariable analysis. CONCLUSION Emergency surgery for colorectal carcinoma in Germany is performed with equal postoperative MTL30 and mortality throughout the entire week. However, emergency surgery during the week seems to be associated with a higher rate of severe postoperative complications and reoperation.
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Affiliation(s)
- Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- * E-mail: (FA); (AW)
| | - Sven Lichthardt
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Imme Haubitz
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Johanna Wagner
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | | | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University Hospital, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, Julius-Maximilians-University of Wuerzburg, Wuerzburg, Germany
- * E-mail: (FA); (AW)
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5
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Murray V, Burke JR, Hughes M, Schofield C, Young A. Delay to surgery in acute perforated and ischaemic gastrointestinal pathology: a systematic review. BJS Open 2021; 5:6363074. [PMID: 34476466 PMCID: PMC8413368 DOI: 10.1093/bjsopen/zrab072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The timeline between symptom onset and operation is ill defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for interventions trialled across Europe. METHODS A systematic review was performed searching MEDLINE and EMBASE databases (1 January 2005 to 6 May 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. RESULTS Sixteen papers, involving 50 653 patients, were included in the analysis. Fifteen unique timepoints were identified in the patient pathway between symptom onset and operation which are classified into four distinct phases. Time from admission to theatre (1-72 hours) and mortality rate (10.6-74.5 per cent) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared with that in survivors. Delays were related to imaging, diagnosis, decision making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality rate following introduction of an acute laparotomy pathway. CONCLUSION Given the heterogeneous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into mortality prediction and audit tools and assist in the assessment of interventions.
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Affiliation(s)
- V Murray
- The University of Leeds Medical School, Leeds, UK
| | - J R Burke
- The John Golligher Colorectal Surgery Unit, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, UK
| | - M Hughes
- The John Golligher Colorectal Surgery Unit, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical & Clinical Sciences, Clinical Sciences Building, St James's University Hospital, Leeds, UK
| | - C Schofield
- Department of Anaesthetics, St James's University Hospital, Leeds, UK
| | - A Young
- Department of Pancreatic Surgery, St James's University Hospital, Leeds, UK
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6
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Somasundram K, Neville JJ, Sinha Y, Agarwal T, Raje D, Sinha A, Sheth H. The weekend effect - How can it be mitigated? Introduction of a consultant-delivered emergency general surgical service. Ann Med Surg (Lond) 2020; 57:315-320. [PMID: 32874563 PMCID: PMC7451998 DOI: 10.1016/j.amsu.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/01/2022] Open
Abstract
Background Poorer patient outcomes for emergency general surgery have been observed in patients admitted to hospital over the weekend. This paper reports the outcomes of a Consultant-delivered service model for weekend admissions and its impact for patients undergoing emergency laparotomy. Methods Operative data was analysed from a prospectively collected database over 5-years. Primary outcome measures were 30-day all-cause mortality and Clavien-Dindo class ≥2 morbidity. Secondary outcomes included time from admission to diagnostic imaging and time to surgery, post-operative length of stay and requirement for Intensive Care Unit admission. Results 263 patients underwent an emergency laparotomy. Overall 30-day mortality was 4.6% and all-cause morbidity was 55.9%. The most common indications for laparotomy were mechanical small bowel obstruction (32.7%) and hollow viscus perforation (30.4%) of the 263 emergency laparotomies, 92 patients in the cohort were weekend admissions (Saturday or Sunday). There was no significant difference amongst patients admitted during the weekend in ASA grade, age, gender, or proportion of patients receiving a pre-operative computed tomography scan, when compared to those during the week. Compared to weekdays, weekend admission was not associated with a significant difference in mortality (5.3% and 3.3%, respectively p = 0.458), all-cause morbidity (p = 0.509), post-operative length of stay (p = 0.681), or Intensive Care Unit admission (p = 0.761). Conclusion A Consultant Surgeon delivered emergency service can avoid the poor patient outcomes associated with weekend admissions and the ‘weekend effect’. Poorer patient outcomes have been observed in patients admitted during the weekend. A Consultant Surgeon delivered model of service delivery ensures peri- and intra-operative Consultant presence for all emergency surgery. Under this model, there was no weekend effect observed.
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Affiliation(s)
- Khevan Somasundram
- Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Jonathan J Neville
- Ealing Hospital, London North West University Healthcare NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - Yashashwi Sinha
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tushar Agarwal
- Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Durgesh Raje
- Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Ashish Sinha
- Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Hemant Sheth
- Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
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Hajibandeh S, Hajibandeh S, Satyadas T. Impact of weekend effect on postoperative mortality in patients undergoing emergency General surgery procedures: Meta-analysis of prospectively maintained national databases across the world. Surgeon 2020; 18:231-240. [DOI: 10.1016/j.surge.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/08/2019] [Accepted: 09/14/2019] [Indexed: 01/01/2023]
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Bakshi SG, Gawri A, Panigrahi AR. Audit of pain management following emergency laparotomies in cancer patients: A prospective observational study from an Indian tertiary care hospital. Indian J Anaesth 2020; 64:470-476. [PMID: 32792710 PMCID: PMC7398025 DOI: 10.4103/ija.ija_45_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/15/2020] [Accepted: 03/16/2020] [Indexed: 11/06/2022] Open
Abstract
Background: Emergency laparotomies present a challenge in pain management given sick patients, odd timings and poor outcomes. Current recommendations favour multimodal opioid-sparing analgesia following elective laparotomies. No recommendation exists for emergency surgeries. Methodology: After approval and registration of the trial, adult patients posted for emergency laparotomy in the hospital (tertiary centre for cancer care) starting August 2015, for 6 months, were included in this prospective study. Patients' details including indication for emergency surgery, preoperative haemodynamic parameters, baseline coagulation status were captured. Patients were followed for pain scores, satisfaction with pain management and outcome. The number of anaesthesiologists present and their experience concerning regional techniques were noted. Results: Intestinal obstruction was the commonest cause of emergency laparotomy. Most patients belonged to the ASA IE/IIE class (91%). Intraoperatively, opioids were the mainstay of pain management with an epidural catheter inserted in only 9% of cases even though most cases were conducted by anaesthesiologists confident/expert in thoracic epidural insertion. There was no correlation of choice of pain management technique with the time of surgery (P = 0.22), ASA grading (P = 0.28), predicted mortality by p-Possum scores (P = 0.24). Pain at movement was moderate-severe in more than 50% of patients within the first 24 h. The regional group had better satisfaction when compared to opioid and non-opioid based management. (P < 0.001). Conclusion: Regional techniques for pain management in emergency laparotomies are less preferred, therefore, opioids are the mainstay. Lack of experience is essentially not the primary reason for regional techniques not gaining popularity. Pain management in this group needs a thorough re-evaluation.
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Affiliation(s)
- Sumitra G Bakshi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ajay Gawri
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Amit R Panigrahi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Powell AG, Williams EA, Edwards P. Letter of response on: "Mode of presentation rather than the 'weekend effect' is a major determinant of in-hospital mortality". Surgeon 2019; 17:383. [PMID: 31445936 DOI: 10.1016/j.surge.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/21/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Arfon Gmt Powell
- Division of Cancer and Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XW2, United Kingdom
| | - E Anwen Williams
- Nevill Hall Hospital, Brecon Road, Abergavenny, NP7 7EG, United Kingdom
| | - Paul Edwards
- Division of Cancer and Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XW2, United Kingdom
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