Simple signage and targeted education can lead to process improvement in acute appendicitis care.

INTRODUCTION: An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration. MATERIALS AND METHODS: Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention. RESULTS: Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005). CONCLUSION: This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.

Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes. METHODS: A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases. RESULTS: In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications. CONCLUSIONS: National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.

Successful implementation of an appendectomy process improvement protocol.

BACKGROUND: A key component of a process improvement program is the institution of hospital-specific protocols to address certain disparities and streamline patient care. In that regard, we evaluated the implementation of an outpatient laparoscopic appendectomy (OLA) protocol at a tertiary military hospital. We hypothesized that OLA would reduce length of stay (LOS) without increasing complications. METHODS: In August 2016, our institution implemented an OLA protocol-defined as discharge within 24 hours of surgery. Exclusion criteria included age <18 years old, grade 4 or 5 appendicitis, immunosuppression, current pregnancy, and no supervision during the first 24 hours postdischarge. To determine OLA's effect on LOS, analysis of variance was used to perform a comparison between the years 2014 and 2017. Successful outpatient appendectomies were recorded preprotocol and postprotocol, as well as readmission complications. RESULTS: In 2017, the first full year of protocol implementation, 44 of 59 (75%) patients met the inclusion criteria, and all but 2 (42 of 44, 95%) stayed for less than 24 hours. Of the two outliers, one developed acute on chronic kidney disease and one had a slow return of bowel function following grade 3 appendicitis. Complications were low across all years (one per year). In 2017, the readmission was for percutaneous drainage of an abscess. Overall, protocol implementation produced a significant decrease in LOS. DISCUSSION: OLA protocol decreased LOS at a military hospital and should be expanded to other department of defense (DoD) facilities. Further research is needed to identify cost benefit to the military health system. LEVEL OF EVIDENCE: III.

Development of an emergency general surgery process improvement program.

BACKGROUND: The Joint Trauma System has demonstrated improved outcomes through coordinated research and process improvement programs. With fewer combat trauma patients, our military American College of Surgeons level 2 trauma center's ability to maintain a strong trauma Process Improvement (PI) program has become difficult. As emergency general surgery (EGS) patients are similar to trauma patients, our Trauma and Acute Care Surgery (TACS) service developed an EGS PI program analogous to what is done in trauma. We describe the implementation of our novel EGS PI program and its effect on institutional PI proficiency. METHODS: An EGS registry was developed in 2013. Inclusion criteria were based on AAST published literature. In 2015, EGS registrar and PI coordinator positions were developed and filled with existing trauma staff. A formal EGS PI program began January 1, 2016. Pre- and post-program data was compared to determine the effect including EGS PI events had on increasing yield into our trauma PI program. RESULTS: In 2016, TACS saw 1001 EGS consults. Four hundred forty-four met criteria for registry inclusion. Eighty-two patients had 131 PI events; re-admission within 30 days, unplanned therapeutic intervention, and unplanned ICU admission were the most common events. Capture of EGS PI events yielded a 49% increase compared with 2015. CONCLUSION: Overall patient volume and PI events post EGS PI program initiation exceeded those prior to implementation. These data suggest that extending trauma PI principles to EGS may be beneficial in maintaining inter-war military and/or lower volume trauma center readiness.

Review of an emergency general surgery process improvement program at a verified military trauma center.

INTRODUCTION: Decreasing combat-based admissions to our military facility have made it difficult to maintain a robust trauma process improvement (PI) program. Since emergency general surgery (EGS) and trauma patients share similarities, we merged the care of our EGS and trauma patients into one acute care surgery (ACS) team. An EGS PI program was developed based on trauma PI principles to facilitate continued identification of opportunities for improvement despite our decline in trauma admissions. Analysis of the first 18 months of combined ACS PI data is presented. METHODS: EGS registry inclusion criteria was based on published Association for the Surgery of Trauma's recommendations. Program components and PI categories were based on our existing trauma PI program. Dedicated coordinators actively reviewed and cataloged patient care and outcomes. Deviations from standard practice patterns, unplanned interventions, and other complications were abstracted, categorized, and evaluated through levels of review similar to accepted trauma PI principles. Data for the first six quarters were collated and trends were analyzed. RESULTS: Over 18 months, 696 EGS patients met registry inclusion criteria, with 468 patients (67%) undergoing operative intervention. Over the same time, 353 trauma patients were admitted with 158 undergoing operative intervention (56.4%). Of the 696 EGS patients and 353 trauma patients, 226 (32%) and 243 (69%) PI events were identified, respectively. Common events included unplanned therapies, re-admissions, and unplanned ICU admissions. Based on analysis of all events, four new areas for improvement initiatives were identified. Results of these initiatives included implementation of a multi-disciplinary EGS PI committee, consensus protocols, and departmental and hospital-wide actions. CONCLUSION: In an 18-month period, integration of our EGS patients into a novel, combined ACS PI program facilitated recognition of an additional 226 PI events and provided a substrate for continued improvements in patient care.