Hybrid electronic record: An error reduction strategy for diverse medical prescription formats.

BACKGROUND:  This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. METHODS:  Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. RESULTS:  There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. CONCLUSION:  Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct.Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma.

INTRODUCTION: The open abdomen (OA) is a necessary component of damage control surgery and closure is often challenging. Our aim was to review our ten-year experience with OA in trauma patients and to compare the success of a dual closure technique termed vacuum-assisted, mesh-mediated fascial traction (VAMMFT) to an exclusively Bogota Bag (BB) approach. METHODS: A retrospective analysis was performed using the HEMR database from 2012 to 2022, comparing demographics, mechanism of injury, admission vitals and biochemistry between patients with BB and VAMMFT applications. Rate of secondary abdominal closure and complications were assessed in both groups. Logistic regression was used to find predictors of closure. RESULTS: OA was required by 348 patients at index laparotomy. Of these, 133 (38.2%) were managed with VAMMFT and 215 (61.8%) exclusively with a BB. There were no statistical differences between the BB and VAMMFT groups in terms of demographics, injuries, admission vitals and biochemistry. The VAMMFT group achieved a closure rate of 73% compared to 54.9% in the BB group (OR of 2.2 [1.4-3.7]). There was no significant difference in fistulation rate between the two groups (p = 0.103). Length of hospital stay was 30 versus 17 days in the VAMMFT and BB groups, respectively (OR 1.41 [1.30-1.54]). There were no independent predictors of closure identified in the VAMMFT group. Older patients were less likely to achieve closure when BB was used (OR 0.97 [0.95-0.99]). VAMMFT failure was commonly due to lack of stock (39%) and protocol violations (33%). CONCLUSION: The VAMMFT approach to the OA is efficacious and safe. VAMMFT achieves a much higher rate of secondary closure than BB alone with a low rate of enteric fistula formation.

Using Machine Learning to Establish Predictors of Mortality in Patients Undergoing Laparotomy for Emergency General Surgical Conditions.

INTRODUCTION: Patients undergoing laparotomy for emergency general surgery (EGS) conditions, constitute a high-risk group with poor outcomes. These patients have a high prevalence of comorbidities. This study aims to identify patient factors, physiological and time-related factors, which place patients into a group at increased risk of mortality. METHODOLOGY: In a retrospective analysis of all patients undergoing an emergency laparotomy at Greys Hospital from December 2012 to 2018, we used decision tree discrimination to identify high-risk groups. RESULTS: Our cohort included 1461 patients undergoing a laparotomy for an EGS condition. The mortality rate was 12.4% (181). Nine hundred and ten patients (62.3%) had at least one known comorbidity on admission. There was a higher rate of comorbidities among those that died (154; 85.1%). Patient factors found to be associated with mortality were the age of 46 years or greater (p < 0.001), current tuberculosis (p < 0.001), hypertension (p = 0.014), at least one comorbidity (0.006), and malignancy (0.033). Significant physiological risk factors for mortality were base excess less than -6.8 mmol/L (p < 0.001), serum urea greater than 7.0 mmol/L (p < 0.001) and waiting time from admission to operation (p = 0.014). In patients with an enteric breach, those younger than 46 years and a Shock Index of more than 1.0 were high-risk. Patients without an enteric breach were high-risk if operative duration exceeded 90 min (p = 0.004) and serum urea exceeding 7 mmol/dl (p = 0.016). CONCLUSION: In EGS patients, patient factors as well as physiological factors place patients into a high-risk group. Identifying a high-risk group should prompt consideration for an adjusted approach that ameliorates outcomes.

Staged laparotomy for acute non-traumatic intra-abdominal emergencies in a tertiary South African unit.

INTRODUCTION: Patients undergoing laparotomy for emergency general surgery (EGS) have poor outcomes. Attempts have been made to improve these outcomes by adopting damage control principles known to benefit polytraumatized patients. Studies describing the use of staged laparotomy (SL) in EGS have been modest in size and heterogenous. The aim of this study was to describe our experience with SL at a tertiary hospital in KwaZulu-Natal, South Africa. METHODS: The Hybrid Electronic Medical Registry (HEMR) at Greys Hospital was interrogated for all consecutive admissions undergoing staged EGS laparotomy. Descriptive and inferential statistics were performed. RESULTS: From 2012 to 2018, 242 patients (16.5% of all EGS laparotomies) underwent SL for an EGS condition. The median patient age was 38 years old (IQR 27-56 years). Physiological indications were present in 125 patients (51.7%) and non-physiological indications (NPI) in 117 (48.3%). Haemodynamic instability was the most common physiological indication (51; 21.1%) and gross contamination was the most non-physiological indication (91; 37.6%). Adverse event and mortality rates were 84.8% and 26.9%, respectively. Independent predictors of mortality were enteric breach (OR3.9; 95% CI (2.1-7.8)), physiological indication (OR 2.1; 95% CI (1.1-3.7)) and anastomosis (OR 2.0; 1.05-3.73). "Clip and drop" did not contribute to mortality (P = 0.43; OR1.34 (0.64-2.7)). Mortality was higher in the group without repeat laparotomy. Mortality rate was not associated with increasing number of relaparotomies. CONCLUSION: Patients undergoing EGS laparotomy form a high-risk group. "Clip and drop" approach and number of relaparotomies were not associated with mortality. Indications and components of this approach need to be standardized.

Spectrum and Outcome of Emergency General Surgery Laparotomies at a Tertiary Center in South Africa.

BACKGROUND: Nontraumatic surgical emergencies constitute a significant portion of total surgical workload and are associated with a significant mortality rate. The spectrum and outcome of surgical emergencies in a low-middle-income country may differ from that in high-income countries. This study aims to describe the spectrum and outcome of emergency laparotomy for nontrauma surgical emergencies at a single-tertiary center in South Africa. METHODS: A retrospective interrogation of a hybrid electronic record system of consecutive patients undergoing emergency laparotomy for nontraumatic surgical emergencies presenting to Greys Hospital from December 2012 to December 2018. RESULTS: One thousand four hundred sixty four patients were included with a median age of 34 y (IQR 23-52) and male predominance (861; 59%). The mortality rate was 12.5% (183). The most common comorbidity was human immunodeficiency virus (353; 24.1%) which did not influence mortality. At least one comorbidity increased the odds of mortality by 4 times (95% CI 2.7-6.2). Mortality was associated with longer waiting times to operation (12.8 versus 8.4 h; P < 0.001) and longer operating times (105 min versus 80 min respectively; P < 0.001). Temporary abdominal closure was used in 245 (16.7%) patients. Planned repeat laparotomy was performed in 193 (13.2%) patients. Acute appendicitis (594, 40.6%) was the most common pathology of which 61.4% had the American Association for the Surgery of Trauma grade of 4 or more (high grade). This was followed by perforated peptic ulcer disease (10.5%). The adverse event rate was 51.5% (754). Postoperative pulmonary complications and acute kidney injury were the most common. The strongest predictors of mortality were abdominal compartment syndrome (OR 26.5, 95% CI 9.36-94.13) and postoperative hemodynamic instability 17.43 (OR 17.4, 95% CI 11.80-25.98). CONCLUSIONS: Our spectrum of disease differs to that found in high-income countries. The morbidity and mortality rates are significant, and attention must be focused on attempts to reduce this. Various comorbidities and adverse events are associated with increased mortality.

Health-Related Behaviours, HIV and Active Tuberculosis are Associated with Perioperative Adverse Events Following Emergency Laparotomy at a Tertiary Surgical Service in KwaZulu-Natal, South Africa.

INTRODUCTION: This project aims to define the common comorbidities associated with patients undergoing emergency laparotomy in South Africa, to review the impact of these comorbidities on outcome and to attempt to model these various factors. METHOD: A retrospective review of all patients undergoing emergency laparotomy for an emergency general surgical condition was performed from the prospectively entered Hybrid Electronic Medical Registry (HEMR). Univariate and multiple logistic regression analysis was performed to establish associations and independent risk factors for developing an adverse event. RESULTS: Over a six-year time period, a total of 1464 patients underwent emergency laparotomy. The median age was 34 years. Males constituted 58.8% (861) of the patients and 754 patients (51.5%) experienced at least one adverse event. The mortality rate was 12 percent. Comorbidities and social factors were documented in 912 patients (62.3%). The rate of adverse events among patients with comorbidities was 59% (538). Patients without comorbidities or significant social factors had an adverse event rate of 39.1% (216). This difference was statistically significant (p < 0.001). The most frequent comorbidity in our sample was HIV, followed by hypertension, underlying malignancy, diabetes mellitus, active TB and cardiovascular disease. CONCLUSION: Emergency laparotomy in South Africa is associated with significant morbidity and mortality. The patients are younger than in high-income countries. Diabetes mellitus, hypertension, HIV and active TB are associated with the development of an AE.

Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for surgical-decision making.

BACKGROUND: The mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system. METHODS: A modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010-2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearman's rho. RESULTS: There were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (n = 37, 73%), pedestrian vehicle accidents (n = 7, 13%), assaults (n = 4, 8%), falls (n = 2, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10-25] and GCS at hospital admission was 15 [15-15]. The median [IQR] international normalized ratio was 1.2 [1.1-1.5], lactate was 2.7 [1.7-4.9], and hemoglobin was 11.4 [8.6-12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy. CONCLUSIONS: We developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed.