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An Evaluation of the Impact of a Dedicated Emergency Surgical Service on the Management and Outcomes of Acute Appendicitis

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An Evaluation of the Impact of a Dedicated Emergency Surgical Service on the Management and Outcomes of Acute Appendicitis

Background

Acute appendicitis remains the most common general surgical emergency, with an annual incidence of 150/100,000 in Ireland1. Optimally diagnosing and managing appendicitis often remains a challenge of intervening before complications such as perforation develop, while avoiding unnecessary operations. Even with readily available imaging modalities negative appendicectomy rates remain as high as 30% in some centres2,3. Negative appendicectomies, as well as incurring unnecessary hospital costs can be associated with significant patient morbidity4 including increased infections5 and prolonged length-of-stay6.

Dedicated Emergency General Surgery (EGS) services have gained popularity in recent times as a means to improve care of unscheduled surgical patients. EGS services facilitate earlier senior assessment and decision making by surgeons freed from elective commitments and more timely intervention in patients who require same. EGS models have been shown to improve outcomes following appendicectomies:

•More laparoscopic operations7
•More daytime operations8
•Shorter length of stay9
•Decreased post-operative complications10
•Decreased negative appendicectomy rate11.
 

Methods

An EGS service was introduced in Cork University Hospital, Ireland in April 2017.

2 full time emergency general surgeons without any elective commitments carried out the majority of acute general surgical call since.

 

Clinical, laboratory, radiological, and pathological data was collected on all appendicectomies performed from January-September 2017. This was divided into Pre-EGS (January-April 2017) and Post-EGS (May-September 2017) cases.

Comparative analysis was performed on this data examining:

•Patient length-of-stay
•Negative appendicectomy rate
•Frequency of imaging modalities used
•Incidence of perforations/complications
•Perioperative complications
•Missed diagnoses (considered as a patient discharged without operation, then representing with appendicitis less than 1 week later)
 

Discussion

Following introduction of a consultant led dedicated EGS service we saw a number of improvements with regards to the management and outcomes of acute appendicitis.

 

An Emergency General Surgery Service led by dedicated consultants reduced the rates of negative appendicectomies and unnecessary operations with the associated risks and costs of same.

 

Earlier clinical assessment and decision making by senior surgeons facilitates earlier use of appropriate imaging modalities. We began to utilise MRI scanning to diagnose appendicitis in paediatric patients, particularly in those with an inconclusive ultrasound. This allowed us to make more accurate diagnoses and reduce our paediatric negative appendicectomy rate without exposing children to ionising radiation.

 

Increased experience of regularly dealing with surgical emergencies requiring operative intervention allowed for more operations to be completed laparoscopically, reducing patient length of stay, post operative complications and readmissions.

 

Conclusions

A dedicated, consultant led, Emergency General Surgical Service reduces the rate of negative appendicectomies, reduces patient length-of-stay and increases the amount of operations performed laparoscopically.

Other hospitals providing acute surgical care may consider introducing a similar service to improve the management and outcomes of patients presenting with acute appendicitis.

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