Choice of First Emergency Room Affects the Fate of Patients With Acute Mesenteric Ischaemia: The Importance of Referral Patterns and Triage

Abstract

WHAT THIS PAPER ADDS Although delay is a key modifiable factor in the treatment of acute mesenteric ischaemia (AMI), few studies have sought modifiable targets to reduce this parameter. This study found that the key factor is the type of emergency room (ER) the patient first encounters. If this ER was non-surgical, the time to surgical operation was approximately 15 h and mortality 75%, compared with 10 h and 50% mortality if the first ER was surgical. This study illustrates that patient pathway is a potential target for improvement in the treatment of AMI and the whole pathway needs to be involved and educated.Objectives: Despite modern advances in diagnosis and treatment, acute arterial mesenteric ischaemia (AMI) remains a high mortality disease. One of the key modifiable factors in AMI is the first door to operation time, but the factors attributing to this parameter are largely unknown. The aim of this study was to evaluate the factors affecting delay, with special focus on the pathways to treatment. Methods: This was a single academic centre retrospective study. Patients undergoing intervention for AMI caused by thrombosis or embolism of the superior mesenteric artery between 2006 and 2015 were identified from electronic patient records. Patients not eligible for intervention or with chronic, subacute onset, colonic only, venous, or non-occlusive mesenteric ischaemia were excluded. Patients were divided into two groups according to the first speciality examining the patient (surgical emergency room [SER], surgeon examining the patient first or non-surgical emergency room [non-SER], internist examining the patient first). The primary endpoint was first door to operation time and secondary endpoints were length of stay and 90 day mortality. Results: Eighty-one patients with AMI were included. Fifty patients (62%) died during the first 30 days and 53 (65%) within 90 days. Presenting first in non-SER (vs. SER) was independently associated with a first door to operation time of over 12 h (OR 3.7 [95% CI 1.3e10.2], median time 15.2 h [IQR 10.9e21.2] vs. 10.1 h [IQR 6.9e18.5], respectively, p ¼ .025). The length of stay was shorter (median 6.5 days [4.0e10.3] vs. 10.8 days [7.0e22.3], p ¼ .045) and 90 day mortality was lower in the SER group (50.0% vs. 74.5%, p ¼ .025).Conclusions: The first specialty that the patient encounters seems to be crucial for both delayed management and early survival of AMI. Developing fast/direct pathways to a unit with both gastrointestinal and vascular surgeons offers the possibility of improving the outcome of AMI.

Delay to surgery in acute perforated and ischaemic gastrointestinal pathology: a systematic review

“…The preimaging phase was assessed in one study by Lemma and colleagues (2019) 26 . They determined an interquartile range of 2.7–10.6 hours from emergency department (ED) presentation to computed tomography (CT) interpretation (median 5.5 hours) and 2.8–12.9 hours from ED to diagnosis (median 6.5 hours).…”

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

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Acute Mesenteric Ischemia: A Challenge for the Acute Care Surgeon

“…It should be kept in mind that there could be a silent on-going cardiac infarction behind any acute embolic event. It has been shown that 20% to 60% of patients with AMI are admitted to non-surgical emergency room such as internal medicine, and this may cause a significant delay of the diagnosis ( 2 , 11 ). In addition, D-dimer may be elevated in embolic occlusion of the SMA ( 4 ).…”