Aim Management of patients with subcutaneous abscesses is challenging. Once in hospital, the majority require incision and drainage (I&D), often under general anaesthetic (GA). Patients placed on emergency lists are frequently superseded, due to being systemically well, often staying overnight in hospital. We assessed how the establishment of a nurse-led, ambulatory service for I&D of abscesses reduced the need for GA, and impacted inpatient stay. Method Multiple digital sources were used to retrospectively collect data for all patients attending our centre for I&D of subcutaneous abscess during two time periods: August-October 2019 (prior to establishment of the ambulatory service) and August-October 2021 (a year after implementation of the service). Location I&D performed, mode of anaesthesia and length of stay were collected. Results In 2019, 102 patients underwent I&D; 87(85%) were drained under GA. In 2021, 73 patients were managed with I&D, but only 41(56%, p<0.001) required GA; 6(15%) cases were accommodated on a day surgery list. In 2019, 37(36%) patients were managed without overnight stay; in 2021 this rose to 46(63%, p<0.001). Extrapolating if an average of one patient requiring I&D attended each day, estimated bed days used per year dropped from 440 in 2019, to 215 in 2021. Conclusion Establishment of a nurse-led ambulatory pathway for I&D of skin abscesses safely and effectively reduces the number of general anaesthetics and inpatient bed days, potentially by half. Patients requiring anaesthetic support should be accommodated on planned day case lists where possible.
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 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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