1297 / Appendicitis management protocol

SPAIN
Classification of the PSP
Type of Patient Safety Practice Not Implemented
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Infection control / Prevention of surgical site infections
Surgical / Invasive procedures There is no specified text here
Topic of the reported practice
Clinical guidelines or pathways
Aim and the benefit of the Patient Safety Practice
 
Acute appendicitis (AA) is the most common cause of abdominal emergency surgery. The lifetime risk of developing an AA is approximately 7% with an estimated incidence of 90-10 cases /100,000 inhabitants / year. It can occur in any decade of life, but it is more prevalent in adolescents and young adults. Surgical management is not free of complications and these strongly increase the morbidity associated with the process, being the most common: incisional infection with rates ranging from 3.3-10.3% and organ space infections (9.4%).
In order to evaluate the results of a common emergency surgical procedure and searching for improvement areas, we carried out a retrospective review of all patients undergoing surgery for AA between January 2013 and March 2015 in the Department of Surgery of HCUZ (n = 415). Of the 415 appendectomy practiced during this period, 85 patients presented postoperative adverse events (20.5%), being the most common the postoperative ileus in 31 patients (7.5%). The rate of wound infection was of 4.8% with an incidence of intraabdominal abscess of 4.8%. We observed an increased frequency of incisional infection in open appendectomy group (OA) compared with laparoscopic appendectomy (LA) (2% vs 11.7%) being statistically significant (p <0.000). There was no significant difference in the incidence of intra-abdominal abscess when analyzing laparoscopic appendectomy (LA) 5.1% vs. open appendectomy (OA) 4.2% (p=0.692) nor in the presence of ileus (7.8% vs 6.7). The average length of hospital stay in days was of 3.82 days (+/- 3,707)
Today there is great variability within the surgical management and outcome of AA based on: surgical approach and technique applied, type of antibiotic used, duration of antibiotherapy, surgical wound closure, etc. Kelmer1 in 2012 published in Annals of Surgery that the standardization of cares can achieve significant results in terms of reducing surgical site infection, hospital stay and patient comfort
Description of the Patient Safety Practice
 
the main aims of this protocol are:
-    Standardizing the management of a common clinical practice, adapting this protocol to the evidence published in the literature.

-    Improving clinical results by reducing postoperative complications. The percentage of patients who presented complications was 20.5% (n = 85). The most frequent complications were: postoperative ileus (n=31 patients, 7.5%), wound infection (n= 20, 4.8%) and intra-abdominal abscess (n= 20, 4.8%). Global data about surgical site infection are similar to those reported in the literature, however if wound infection is analyzed in specific subgroups we observed it was significantly more frequent (2% vs 11.7%) in the OA versus LA group (p <0.000). On the other hand there was no significant difference (p 0.692) when analyzing the incidence of intra-abdominal abscess depending on the surgical approach (5.1% LA vs 4.2% OA). At this point the purpose of our guide is to reduce the rate of surgical wound infection and intra-abdominal abscess by encouraging the use of the laparoscopic access and applying the antibiotic prophylaxis recommendations established by our hospital PROA group.

-    Improving length of hospital stay. The average stay is an indicator of effectiveness that evaluates the time that the hospital needs to perform the diagnosis and treatment of diseases. The average stay of our series was of 3.82 days (+/- 3.707). Comparing days of hospitalization in the different subgroups described in table no 1 we observed higher hospitalization in OA (4.01 days +/- 4,855) vs 3.75 days +/- 3,129 in LA group; we also found higher hospital stay in the group of patients who had suffered postoperative complications (7.49 ± 6.019) vs does who had not undergone postoperative complications (2.88 ± 1.91), and in those patients defined as "complicated appendicitis" grouped in the intraoperative finding (5.45 +/- 4,855 days) vs those described as "no complicated" (2.39 +/- 1.369 days). We consider this parameter an important value of the clinical effectiveness, since complications and adverse effects prolong the hospitalization.
    In response to these issues, we propose three paths:
•    Early discharge within 24 hours that has proven to be safe and feasible if adequate patient selection is made. We consider that this range of action will benefit patients with non-complicated appendicitis and no comorbidities, even though nowadays, some series describe a rapid discharged similar to an ambulatory process (<12h) with good results in terms of readmission and morbidity2
•    Hospitalization increases with postoperative complications, so the introduction of measures such as: optimization of the patient, appropriate antibiotic treatment, laparoscopic approach etc. would decrease complications resulting in a reduction of stay.
•    In our series comparing with the literature, there was a high rate of AA defined as complicated appendicitis that is directly related with a longer hospitalization rate. Another purpose for the implementation of this protocol is to adequate timings and medical care, decreasing the interval from the evaluation of the patient to diagnosis by trained personnel at the emergency department, offering early consultation with the surgical team on guard that should be prepared to apply a suitable surgical care.
Another parameter we think should be considered to evaluate the quality of care is the costs of the process. Appendectomy is a surgical procedure with an average cost of 3.106,00€ (SALUD INFORMA). Each day of hospitalization represents 685,00€, a specialized care consultation 49,00€ and consultation in the emergency department 136,00€. In our series 330 patients (79.5%) showed no postoperative complications with 2.88 (± 1.91) hospitalization days, in this group of patients, globally 424,974€ could be save, considering a 24 hours reduction stay. On the other side, it is well known that postoperative complications increases health spending. So surgical site infection or intaabdominal infection involves additional costs resulting local treatment, antibiotics, prolonged hospital stay and/or requiring in some cases reoperation.
Attachment of relevant written information and/or photos, as appropriate
2015113002502728762_WP4_APPENDICITIS MANAGEMENT PROTOCOL.pdf
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
No
Level of implementation of reported practice
There is no specified text here
Specific and measurable outcome for the reported practice were defined
There is no specified text here
A baseline measurement before implementation of the reported practice was obtained
There is no specified text here
A measurement after full implementation of the reported practice was obtained
There is no specified text here
Evaluation of a "positive" effect of the reported practice on Patient Safety
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Type of before-and after evaluation
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Enclosure of a reference or attachment in case of published evaluation's results
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Health care context where the Patient Safety Practices was implemented
 
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Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Yes
Specification of implementation in another health care setting(s)
Hospital
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple local/national health systems
Involved health care staff
 
Physicians
Nurses
Clinical support
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient(s)
Relative(s)
Point of time in which service user or their reprasentatives' involvement takes place
During the application of the Patient Safety Practice
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Not evaluated
Short description of the service users' level of involvement
Consultation, such as asking for information
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
Brochures
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
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List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Regular data feed back to involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Not relevant
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
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Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
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Contact information
 
Name: Estibaliz Echazarreta-Gallego
Country: SPAIN
Organisation: Hospital Clínico Universitario de Zaragoza
E-mail: esti.egallego@hotmail.com
Phone: +34690336742
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