Introduction With the NHS under increasing pressure, the number of patients being referred to secondary care is increasing. Ambulatory clinics are being set up to reduce admission in some patient groups. In our unit, GP referrals to General Surgery were previously being accepted to the admissions ward, without triage. A new system which allowed referrers to contact senior on-call team members was trialled to identify whether patients could be safely diverted to an ambulatory clinic, avoiding inpatient admission. Methods A cascade triage system of referrals was trialled between September 2021 and January 2022, over a total of 30 days. Data were collected on who triaged the call, outcome of the call, and admission rate of patients. Results Some 195 calls were analysed. Consultants were able to divert 62%(66/106) of patients to an ambulatory clinic compared to 30%(14/46) for junior doctors and 35%(15/43) for specialist nurses(p<0.001). The overall admission rate was 50%, with half of patients being successfully managed ambulatorily. Improvement was shown over time in triage by junior doctors, with 1/10 in first 10 patients versus 4/10 in the final 10 patients triaged to the ambulatory clinic. Average weekday admissions to the ward dropped from 12.1, to 7.5 on trial days. Conclusion The trial has demonstrated senior decision makers are the most effective at directing patients to an ambulatory pathway, while junior doctors have scope to improve their skills with experience. Clinician triage is successful at reducing the number of surgical admissions when there is access to an ambulatory clinic.
Aims Previously, guidelines for the management of diverticular disease have recommended endoscopic evaluation following acute diverticulitis to exclude colorectal cancer (CRC). However, 2021 ACPGBI consensus guidelines recognised the sensitivity of modern CT scanning and low incidence of CRC, and suggested no routine re-imaging in CT-proven uncomplicated disease. Methods Patient were identified presenting between 2017–2019 at a single centre. Records were retrospectively reviewed to evaluate the incidence of CRC at a minimum of 18-month follow up in this patient group. Secondary outcomes included the imaging method requested, operative management, and complications following endoscopy. Results Of 486 admissions in 461 patients, 168 (35%) had CT-proven complicated disease, 225 (46%) had uncomplicated, and 93 (19%) had no imaging. 281 (59%) had follow-up investigations requested; 126 CT colonoscopy (CTC) and 150 endoscopic. 133 investigations were performed in patients with uncomplicated diverticulitis. Only 6 patients (1%) were diagnosed with CRC; 2 at endoscopy, and 4 by histology from colorectal resections during emergency admission; all had CT-proven complicated diverticulitis. No malignancy was identified in patients with uncomplicated diverticulitis. Secondary outcomes identified that 26 (24%) flexible sigmoidoscopies were poorly tolerated, necessitating further imaging. Conclusions At our centre, there was little consensus on whether patients had follow-up imaging following acute diverticulitis, and what modality was used. We identified no CRC in patients with CT-proven uncomplicated disease, with 133 potentially unnecessary investigations performed in this group. We recommend use of CTC or endoscopy following acute CT-proven complicated diverticulitis in line with ACPGBI guidelines, avoiding follow-up in uncomplicated disease.
Aims With the progression of minimally invasive surgery across surgical specialties in the elective setting, we aimed to assess the translation of laparoscopic surgery into emergency surgery in our district general hospital. The National Emergency Laparotomy Audit (NELA) provides us with an excellent database to review our single-centre's experience over time. Methods Using data collected as part of the NELA, we reviewed available operations between 2013 and 2021 at our centre, and compared outcomes between open, laparoscopic, laparoscopic-assisted (LA), and laparoscopic-converted-to-open (LCTO) operations. The primary outcome was mortality. Our secondary outcomes were variables that guided decision to operate laparoscopically versus laparotomy. Results 1236 operations were identified; 205 (17%) were either laparoscopic, LA, or LCTO. 60-day mortality in all laparoscopic groups was significantly lower at 4.4% compared with 10.0% in the open group (p-value 0.008). This finding was lost when variables of age, ASA grade, or pre-operative P-possum mortality were adjusted for. Conclusion Laparoscopic surgery was performed on a small, selected group. It is a safe and valuable choice for many patients, particularly with upper-GI pathology and may contribute to improved mortality. However, whilst at first glance laparoscopic approaches to the emergency surgical abdomen appear to improve mortality, this likely represents a well-known clinician-led process of selecting patients with greater fitness and lower predicted pre-operative mortality, therefore muddying the significance of this apparent benefit. This is comparable with national data.
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