Outcomes of emergency colorectal surgery in elderly population.

OBJECTIVES: To assess the outcomes of emergency colorectal surgeries in elderly patients over the age of 65 years. METHODS: This is a retrospective chart review study. We studied 99 patients over the age of 65 years and 142 patients younger than 65 years who underwent emergency colorectal surgery at our institute. In this study, patient demographics, operative results, length of hospital stay, and survival were analyzed. RESULTS: Emergency colorectal surgery was performed on a total of 145 men and 96 women. Patients over the age of 65 years were found to have a significantly greater proportion of pulmonary, cardiac, and endocrine comorbidities (27.3%, 84.8%, and 65.7%, respectively). The mean length of hospital stay was 26.0±32.1 days in the group of elderly patients and 17.8±22.0 days in the group of patients under the age of 65. The length of postoperative hospital stay was significantly greater in the group of elderly patients with a p-value (0.00). The length of hospital stay in the intensive care unit was 8.86±17.1 days, which was longer in the group of elderly patients, while it was 3.65±11.4 days for the group of younger patients. However, after logistic regression, the difference in the length of post-operative hospital and intensive care unit stays between elderly and non-elderly patients was not statistically significant in elderly patients. CONCLUSION: Our study suggests that the elderly population are associated with longer hospital stay and higher rates of postoperative pulmonary and cardiovascular complications compared to those under the age of 65. However, after logistic regression, age by itself was not found to be an independent risk factor for worse outcome indicating that patient comorbidities as a whole increase the risk of worse outcomes. Therefore, the care of elderly patients undergoing emergency colorectal surgery should be individualized based on several factors rather than age alone.

Outcomes of emergency appendectomies and cholecystectomies performed at weekends.

PURPOSE: To determine the impact of hospital admissions and operations at weekends on two common emergency general surgeries (cholecystectomy and appendectomy) and their outcomes. METHODS: A total of 539 patients were included in the study. Information on patient demographics, comorbidities, admission date, surgery date, complications, readmission, and follow-up details were collected from electronic medical records. RESULTS: Most patients were admitted to hospital on weekdays (n = 391), and 444 surgeries were performed on weekdays, while 86 surgeries were performed at weekends. No significant difference was found between the type of surgery performed on weekday and weekend admissions (P = 0.384). Surgical procedures of patients admitted to hospital on a weekend tended to be delayed by a median of one day compared with weekday admissions, with a similar overall length of stay for both groups. Weekend admissions were associated with higher complication rates than weekday admissions (12.2 vs. 6.1%). Patients who were operated on at weekends were younger in age than those admitted on weekdays (32 vs. 30 years old, P = 0.019). More appendectomies were performed at weekends (77.9% vs. 45.9%), and fewer cholecystectomies were performed (22.1 vs. 54.1%, P = 0.000). CONCLUSIONS: The surgical procedures of patients admitted to hospital on weekends tended to be delayed by 1 day and had a higher rate of complications. Appendectomy was the most common performed weekend surgery.

A case of intestinal obstruction in a 90-year-old patient at a tertiary hospital in Central Saudi Arabia with a rare cause: obturator hernia!

Obturator hernia is a pelvic floor type of hernia in which abdominal or pelvic contents protrude through the obturator foramen. It is considered rare in patients with signs and symptoms of intestinal obstruction causing a diagnostic challenge for clinicians. This case reports a 91-year-old multiparous female who presented with vague lower abdominal pain associated with obstipation and vomiting. We present a successful laparoscopic repair of obturator hernia in an elderly female.

Impact of GI Tumor Board on Patient Management and Adherence to Guidelines.

PURPOSE: As the burden of cancer on the population and the health care system continues to increase with more complicated treatment options, the need for multidisciplinary teams to be as efficient as possible becomes more vital. Our study aimed to evaluate the consistency of GI Tumor Board (GI TB) recommendations with international guidelines, the adherence of physicians involved in patient care to TB recommendations, and the impact on the management of patients. METHODS: A prospective cohort study was conducted from January to June 2016 at our institution, which is a major tertiary hospital that provides comprehensive cancer care. All cases presented at the GI TB during this period were included. Data regarding adherence to National Comprehensive Cancer Network guidelines, adherence to TB recommendations, and changes made to the management of patients were collected weekly from the GI TB in a data collection form. RESULTS: Of the 104 patients included, 57 (55%) were males and the median age was 58 (16 to 85) years. Colorectal cancer was the most common diagnosis, in 65 patients (63%). Nearly one-half of cases (45%) were stage IV cancers. Starting new treatment was recommended for 72 patients (69%). Further investigations were requested for 15 patients (14%). For imaging, 24 recommendations (23%) were made. Adherence to National Comprehensive Cancer Network guidelines was observed in 97% of total recommendations. New findings were found in pathology (11%), radiology (13%), and staging (4%). Management plans were changed in 37 cases (36%). Over a 3-month period after presentation to the GI TB, most of the recommendations (87%) were performed. CONCLUSION: A multidisciplinary tumor board enhances the adherence to guidelines and has an impact on patient management in approximately one-third of patients. Among physicians, adherence to recommendations of the TB was high.

Outcomes of common general surgery procedures for patients discharged over weekends at a tertiary care hospital in Saudi Arabia.

BACKGROUND: Hospitals usually reduce staffing levels and services over weekends. This raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk of adverse events post-discharge. OBJECTIVES: To assess the outcomes of common general surgery procedures for patients discharged over weekends, and to identify the key predictors of early readmission. DESIGN: Retrospective cohort study. SETTING: A tertiary care center. PATIENTS AND METHODS: Patients discharged from general surgery services during the one-year period between January and December 2016 after cholecystectomy, appendectomy, or hernia repairs were included. Patient demographic information, comorbidities, and complications as well as admission and follow-up details were collected from electronic medical records. MAIN OUTCOME MEASURES: Outcomes following weekend discharge, and the predictors of early readmission. SAMPLE SIZE: 743 patients. RESULTS: The operations performed: 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. A significantly lower number of patients were discharged over the weekend (n=125) compared to those discharged on weekdays (n=618). Patients discharged during the weekend were younger, less likely to have chronic diseases, and had a significantly shorter average length of stay (LOS) (median 2 days, IQR: 1, 4 vs. median 3 days, IQR: 1, 5, P=.002). Overall, the 30-day readmission rate was 3.2% (n=24), and weekend discharge (OR=2.25, 95% CI 0.52-9.70) or any other variable did not predict readmission in 30 days. However, 14-day post-discharge follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, P=.006). CONCLUSION: Weekend discharge was not associated with higher readmission rates. Physicians may consider discharging post-operative patients over a weekend without an increased risk to the patient. Day of discharge, length of stay and increased patient age are not predictors of early readmission. LIMITATIONS: Single-center study and retrospective. CONFLICT OF INTEREST: None.

Enhancing the performance of gastrointestinal tumour board by improving documentation.

Tumour board contributes to providing better patient care by using a multidisciplinary team approach. In the efforts of evaluating the performance of the gastrointestinal tumour board at our institution, it was difficult to assess past performance due to lack of proper use of standardised documentation tool. This project aimed at improving adherence to the documentation tool and its recommendations in order to obtain performance measures for the tumour board. A multidisciplinary team and a plan were developed to improve documentation. Four rapid improvement cycles, Plan-Do-Study-Act (PDSA) cycles, were conducted. The first cycle focused on updating the case discussion summary form (CDSF) based on experts' input and previous identified deficiencies to enhance documentation and improve performance. The second PDSA cycle aimed at incorporating the CDSF into the electronic medical records system and assessing its functionality. The third cycle was to orient and train staff on using the form and launching it. The fourth PDSA cycle aimed at assessing the ability to obtain tumour board performance measures. Adherence to completion of the CDSF improved from 82% (baseline) to 94% after the fourth PDSA cycle. Over 104 consecutive cases discussed in the tumour board between January and July 2016 and 76 cases discussed in 2015, results were as follows: adherence to National Comprehensive Cancer Network guidelines in 2016 was observed in 141 (95%) recommendations, while it was observed in 90 (92%) recommendations in 2015. Changes in the management plans were observed in 37 (36%) cases in 2016 and in 6 (8%) cases in 2015. Regarding tumour board recommendations, 87% were done within 3 months of tumour board discussion in 2016, while 69% were done in 2015. Implementing electronic standardised documentation tool improved communication among the team and enabled getting accurate data about performance measures of the tumour board with positive impact on healthcare process and outcomes.

Physicians' attire. Parents preferences in a tertiary hospital.

OBJECTIVES: To assess Saudi mother's preferences regarding Saudi children's physicians' attire, and its influence on the parents' level of trust and confidence. Methods: A cross-sectional survey was conducted from January to April 2014. Our sample comprised mothers of pediatric patients in both inpatient and outpatient settings at National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Mothers answered multiple questions, including their preferences regarding male and female pediatric physicians' attire, their preferences regarding their children's physician's gender, and the impact of physician's appearance on mothers' confidence. Results: There were 259 female participants. Of all caregivers, 51.4% were 32-years-old or younger. Of those, 170 (65.6%) were educated (had completed high school or higher). Forty-four percent preferred that male physicians wear scrubs, while 5.4% preferred formal attire (tie, shirt, and trousers) and 27.8% preferred Saudi national attire (Thobe and shemagh). Most caregivers (57.9%) preferred that female physicians wear long skirts. Most caregivers (87.6%) preferred physicians to wear a white coat. Most (89.2%) believed that a physician's appearance is very important. Conclusion: Gender of the treating physician is insignificant to mothers. However, the level of trust in a physician is related to his/her external appearance. Most mothers prefer their children's physicians to wear scrubs.