The role of treatment delays in surgical site infection after appendicectomy in a South African rural regional hospital.

BACKGROUND: Delays to surgery for acute appendicitis in low- and middle-income countries lead to significant morbidity. OBJECTIVES: To investigate the role of time to surgery in the development of complicated appendicitis and surgical site infection (SSI) in a rural referral hospital in South Africa (SA). METHODS: A prospective cohort study was conducted of all patients presenting to a regional hospital in SA with acute appendicitis during 2017. Inpatient interview and data collection were followed by 30-day post-surgical follow-up to assess time periods to surgery and operative outcomes. RESULTS: A total of 188 patients underwent surgery for acute appendicitis. The median (interquartile range (IQR)) age was 19 (3 - 73) years, and 62% were male. The median (IQR) time from symptoms to surgery was 60 (42 - 86) hours and from hospital admission to surgery 8 (4 - 16) hours. Forty-one percent were managed laparoscopically, 62% had complicated appendicitis, and 25% developed SSI. Time from symptoms to surgery >72 hours was associated with an increased risk of complicated appendicitis (odds ratio (OR) 4.32; 95% confidence interval (CI) 1.36 - 13.75; p=0.013). Patients with SSI had an increased median delay of 15 hours (p=0.05) compared with those without SSI. Multivariable analysis showed that the risk of SSI increased with complicated appendicitis (OR 8.96; 95% CI 2.73 - 29.41; p<0,001) and decreased with laparoscopic surgery (OR 0.21; 95% CI 0.07 - 0.59; p=0.003). Time to surgery had no effect on the risk of SSI in adjusted analyses. CONCLUSIONS: Delays to surgery beyond 72 hours significantly increased complicated appendicitis, an important risk factor for SSI. Access to facilities with surgical capability and the use of laparoscopic surgery are modifiable risk factors for SSI.

The effect of the introduction of an electronic booking system to appropriately prioritise gastroscopies at a regional hospital in South Africa.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) guidelines state that patients with dyspepsia as well as alarm symptoms, or those that are 55 years and older with new onset dyspepsia, urgently require an upper endoscopy within two weeks. The 'Be Clear on Cancer Campaign' launched by Public Health England estimated that 9% of deaths due to gastric and oesophageal cancers could have been avoided if the diagnosis was made at an earlier stage. Worcester Provincial Hospital (WPH) is a regional hospital in the Western Cape, South Africa, that due to resource constraints was unable to comply with these guidelines. An electronic endoscopy booking system was implemented in June 2014 to assist referring clinicians. OBJECTIVES: To evaluate the ability of the booking system to appropriately prioritise and accommodate clinically appropriate patients for an urgent gastroscopy within 2 weeks at WPH. METHODS: Retrospective analysis of patients booked for urgent gastroscopies using the online booking system at WPH from July 2014 to June 2017. RESULTS: A total of 1 589 gastroscopies were performed, with 1 085 (65%) categorised as urgent by the booking system algorithm, during the study period. The median (interquartile range) waiting time for urgent gastroscopies was 19 (8 - 31) days and 437 (40%) patients underwent a gastroscopy within the recommended 2-week period. Of the patients undergoing gastroscopy within 2 weeks, 87 (20%) were diagnosed with upper gastrointestinal malignancies and 73 (17%) had significant benign pathology (stricture or ulcer). A total of 150 malignancies were diagnosed in the urgent patients of whom 87 (58%) were scoped within 2 weeks. CONCLUSIONS: The volume of patients requiring urgent gastroscopy at WPH outstrips the available resources. The introduction of the online algorithm-based booking system was effective in prioritising patients. The use of this system facilitated a malignancy diagnosis rate which compares favourably with similar fast track endoscopy services in more developed countries.

Thirty-day readmission rate: A predictor of initial surgical severity or quality of surgical care? A regional hospital analysis.

BACKGROUND: Unplanned readmission within 30 days is currently being used in high-income countries (HICs) for measuring the quality of surgical care. Surgical site infection (SSI), abdominal complaints and pain are the most common causes for such readmission. The correlation between readmission rates and mortality, increased patient volumes and complexity of surgery remains controversial. OBJECTIVES: To explore the risk factors for unplanned readmission in the surgical population in a low- and middle-income country setting. METHODS: This is a retrospective review of prospectively collected data of unplanned 30-day readmissions from January 2014 to December 2017 in the Department of General Surgery, Worcester Hospital, South Africa (SA). Basic patient demographics, reasons for readmission, operative urgency and severity, wound class, length of stay and final outcomes were used to compare the inpatient cohort and identify predictors for unplanned readmission. RESULTS: A total of 9 649 patients were admitted to the general surgery department at Worcester Hospital - 2.87% (n=270) were unplanned readmissions within 30 days. The mean age of this cohort was 42 (standard deviation (SD) 22) years, with 61% male patients. SSI (60.37%; n=163), gastrointestinal complications (24.44%; n=66) and blood transfusion (7.03%; n=19) were the most common causes for readmission. Median initial length of stay (LOS) was 4 days; after readmission it was 5 days. Readmissions were responsible for 1 914 additional patient days. Operative Portsmouth-POSSUM (P-POSSUM) (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) score (p<0.001), increase in operative wound classification (p=0.001) and emergency surgical procedures (p=0.001) were significant risk factors for readmission within 30 days. CONCLUSIONS: The Department of General Surgery, Worcester Hospital, had a readmission rate comparable with that in HICs. Readmission rate is an indicator of advanced surgical pathology requiring an operative intervention of greater magnitude, often presenting as an emergency. Our results can be used to improve postoperative surveillance and ultimately improve outcomes in high-risk surgical populations. This study provides a benchmark for other regional hospitals in SA and has implications for quality-improvement programmes.

Bilateral internal carotid artery occlusion with compensatory perfusion in a HIV-infected patient.

BACKGROUND: Worcester Hospital is a regional healthcare facility in the Western Cape, South Africa, without a dedicated burns unit. Currently there is limited data available of burns patient management outside of academic institutions in South Africa. To describe the incidence and demographics, and to determine the outcomes of burn patients admitted to Worcester Hospital. METHODOLOGY: A retrospective descriptive study of burn patients admitted to Worcester Hospital between 1 September 2016 and 31 August 2017. RESULTS: A total of 66 burn patients were included in this study which accounted for 1.6% of the total surgical admissions for this time period. The mean age of the patients was 39 (SD ± 19) years with a male predominance (59%). The mechanism of burn was mostly flame burns (71%); 16 patients (24%) were burned with hot fluids and 3 patients (5%) sustained electrical burns. The median TBSA was 9% (IQR: 5-28). Ten patients (15%) required critical care unit admission. The burn patients' median length of stay was 6 days (IQR: 2-11 days) versus 2 days (IQR: 1-5 days) for non-burn general surgery patients. Fifty burn patients (76%) required surgical intervention comprising of either debridement or skin grafting, or a combination of this. Forty-four patients (67%) underwent skin grafting procedures and the median TBSA grafted was 5% (IQR: 3.5-9.5). The median time from admission to first surgical procedure was 25 hours (IQR: 18.33-51.08). The in-hospital mortality rate was 23% and of the 15 mortalities, 9 patients (60%) had TBSA of 30% or more and therefore classified as a major burn. CONCLUSION: Burn injuries treated at Worcester Hospital are often severe and require significant resources. This study supplies critical information regarding the burden of burn related injuries managed at a regional level.

Four-year review of admissions to a South African regional hospital general surgery department.

BACKGROUND: There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) context. OBJECTIVES: To retrospectively review data from an electronic discharge summary  database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admitted. METHODS: All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems - Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysis. RESULTS: Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 - 43.8) and a mean length of stay of 4.9 days (95% CI 4.7 - 5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 years. CONCLUSIONS: A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information.