Emergency Laparoscopic Cholecystectomy: Is Dedicated Hot Gall Bladder List Cost Effective?

BACKGROUND: Acute presentation of gall stone disease is a common emergency. Resource limitation often results in unnecessary long waiting times and repeat hospital admissions. The aim of this study was to investigate if funding a dedicated hot gall bladder list is justified. METHODS: Patients with acute gall stone related complications between 1st January 2016 and 31st December 2017 were studied. Outcome measures included the number of acute admissions, length of hospital stay (LOS), approximate cost per patient. The length of stay was identified as a critical outcome measure. RESULTS: Fourteen hundred and ninety-five (11%) out of 14189 acute surgical admissions were related to gall stone complications. These included acute cholecystitis 576 (39%), biliary colic 485 (32%), pancreatitis 405 (27%) and jaundice 34 (2%). Twelve hundred and twenty-two patients accounted for 1461 admissions. 182 (15%) patients had recurrent admissions (35%) and on average stayed 11.2 days in the hospital compared to 5.8 days for that of single presentation. The cost of emergency LC (£2053) was less than half of elective LC following single emergency admission (£5661) and less than one third of Elective LC following recurrent admissions (£7453). A trust can save £1,891,784 per year by achieving 80% target. The savings can be used to fund a dedicated hot gall bladder list, releasing hospital beds and additional benefit of reducing the workforce days lost to sickness in general. CONCLUSIONS: Emergency LC is cost effective and savings made for such a service is sufficient to fund a dedicated hot gall bladder list..

Patient's views of the consent process for groin hernia repair: Use of consent template improves compliance with best practice (Original research).

BACKGROUND: Informed consent obtained for day case surgery has been historically incomplete. An assessment of consenting practice for groin hernia was performed relative to existing gold standards and patient's perception of the consent process was evaluated with a questionnaire. The aim of the study was to identify areas of improvement to comply with best practice. METHODS: A retrospective audit of adult patients undergoing groin hernia repair (June-November 2016) at a tertiary care centre was performed. The same cohort of patients was surveyed with a self-administered questionnaire to identify their view on consenting practice. RESULTS: 113 patients were identified who underwent groin hernia repair during the study period. Pre-printed consent templates-stickers (as opposed to hand-written) were used in 53(47%) cases. In 75(66%) cases, there was complete documentation of the risks and benefits of surgery. 81(72%) patients received information about the full benefits of surgery. 27(23%) patients received partial information and 7(6%) patients had no mention of benefit recorded. Postoperative recovery was fully explained to 85(75%) patients. Use of pre-printed templates ensured 100% documentation compared to handwritten consent forms (risks 37%, benefits 47%, and recovery 53%). Preference for the timing of consent was in clinic (64%), day of surgery (25%). 34(56%) felt the choice for the technique and 22(36%) felt the choice for anaesthesia. Satisfaction was non-significantly better in those consented in clinic (87% versus 76% p = 0.74). 49(80%) felt happy with the overall consent process. 57(93%) felt that they received support and advice. 60(98%) responders felt confidence in the National Health Service and 59(97%) would recommend treatment to family and friends. CONCLUSIONS: The use of pre-printed consent and discharge summary templates improve compliance with best practice. Whilst patient preference favours consent in the outpatient clinic, satisfaction levels were high wherever consent was obtained. Patients should have more choice.

Systematic evaluation of quality of care provided to patients undergoing pulmonary surgery helps to identify areas for improvement.

Systematic assessment of care pathways may identify areas of potential improvement beyond that generated by traditional outcome measures alone. This approach was used to audit a single-surgeon's practice of pulmonary resection [182 patients over 21 months, median age of 69 (range 18-86) years] by choosing 10 gold standards in three areas of care. Preoperative: 1) Percentage cancer patients undergoing PET scan prior to surgery, 2) Percentage of patients with predicted postoperative FEV(1) (ppoFEV(1)) <40% who had gas transfer (DLCO) measured. Perioperative: 3) Percentage of operations postponed, 4-5) Percentage of cancer patients undergoing anatomical resections and systematic lymph node excision, 6) Rate of exploratory thoracotomies. Postoperative: 7-8) Risk-adjusted mortality according to thoracoscore and ESOS.01, 9) Percentage patients admitted to intensive care unit (ICU), and 10) Percentage patients discharged directly home from our unit. Postoperative mortality (2.2%), ICU admission (4%), exploratory thoracotomy (2.7%), and home discharge (98%) fared within standards. Only 57% of patients with a ppoFEV(1)<40% had DLCO tested, and eight cases (4.4%) were postponed on the day of surgery. Analysis of the processes of care identified areas for improvement (preoperative preparation of patients, theatre cancellations and intraoperative lymph node management) even in a practice with satisfactory risk-adjusted results.