Background Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). Methods Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. Results The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26–49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1–4] days vs. 3 [2–4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. Conclusion COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Background Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Abstract Background older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014–2017) since NELA was established. Methods patient-level data were populated from the NELA data set years 1–4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. Results in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P &lt; 0.001) and 90-day mortality (20.4 versus 7.2%, P &lt; 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P &lt; 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P &lt; 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1–4 (8.5 to 16.5%, P &lt; 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35–0.42, P &lt; 0.001; 90-day OR 0.6, CI 0.56–0.65, P &lt; 0.001). Conclusions older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.

Background and objectivesA clinical trial in 93 NHS hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care-pathway implementation and to study the relationship between care-pathway implementation and use of six recommended implementation strategies. MethodsWe performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. Care-pathway implementation was defined as achievement of >80% median reliability in ten measured care-processes. Mean monthly process performance was plotted on run-charts. Process improvement was defined as an observed run-chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal. ResultsOf 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20,305 patient admissions over 27 months. No hospital reliably implemented all ten processes. Overall, only 279 of the 800 processes were improved (3 [2-5] per hospital) and 14/80 hospitals improved more than six processes. Mortality-risk documented (57/80 [71%]), lactate measurement (42/80 [53%]) and cardiac-output guided fluid therapy (32/80 [40%]) were most frequently improved. Consultant-led decision making (14/80 [18%]), consultant review before surgery (17/80 [21%]) and time to surgery (14/80 [18%]) were least frequently improved. In hospitals using ≥5implementation strategies, 9/30 (30%) hospitals improved 6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. ConclusionOnly a small number of hospitals improved more than half of the measured care-processes, more often when at least 5 of 6 implementation strategies were used. In a longer-term project this understanding may have allowed us to adapt the intervention to be effective in more hospitals. BACKGROUNDAs the volume of surgical procedures performed worldwide continues to increase [1,2] the need for improvement in the quality and safety of surgical care has become a global healthcare priority [3][4][5]. This is of particular importance considering both the increasing age and complexity of the surgical population and the global mortality burden associated with surgery [6,7]. Emergency abdominal surgery is a commonly performed procedure worldwide, with high mortality rates, and wide variations in the standards of care [8][9][10][11]. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was performed to test whether a national quality improvement (QI) programme to implement a carepathway could reduce 90-day mortality following emergency abdominal surgery [12].The EPOCH trial intervention consisted of an evidence based care-pathway designed to improve patient o...