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09-08-2011 | Surgery | Article

Emergency department factors affect care of bowel obstruction patients


Free abstract

MedWire News: Modifiable emergency department (ED) and hospital factors negatively affect the timely delivery of patient care and result in delays in treatment among patients experiencing small-bowel obstruction (SBO), show US study findings.

"Timely diagnosis and treatment are critical to reduce untoward outcomes for this time-sensitive condition and require efficient communication and coordination between surgical teams and ED physicians," say Ula Hwang (Mount Sinai School of Medicine, New York) and co-authors in The American Journal of Surgery.

Hwang and team performed a retrospective study of 193 ED patients presenting with SBO at a tertiary care medical center from 2001 to 2002. Medical records, administrative databases, and staffing schedules were evaluated to assess time to first treatment (nasogastric tube or surgery) and risk for surgical resection.

On average, four resident physicians, three attending physicians, and 16 nurses were available during the first hour of arrival to the ED. Most patients were examined during the first hour of arrival, with a median time to examination of 45 minutes.

Surgeons consulted on 76% of patients, with the median time to surgery consult taking 265 minutes. In total, 5% of patients arrived to the ED during hand-off of patients for a shift change.

Of the 152 patients who were not assigned bowel rest, 38% received only nasogastric tube decompression, 19% had surgery only, and 43% had both, with 48% of those requiring surgery treated with bowel resection.

Longer time to first treatment was significantly associated with longer time to surgical consult (hazard ratio [HR]=0.69, 0.49, and 0.36 for <167 min vs 167-265 min, 266-544 min, and >544 min, respectively) and arriving during a ED change of shift (HR=0.40).

Having a longer time to surgical consult reduced patients' chances of having a faster time to treatment, with hazard ratios (HRs) of 0.69, 0.49, and 0.36 for the first quartile of time to surgical consult (<167 min) versus the second (167-265 min), third (266-544 min), and fourth (>544 min) quartiles.

Also, arriving during a ED change of shift was associated with an HR of 0.40 for a faster time to treatment.

Physician diagnostic certainty of obstruction as the primary diagnosis was not significantly associated with time to treatment.

The risk for having surgery and bowel resection increased with increasing time to surgical consultation after adjusting for patient demographic and clinical characteristics, causes of bowel obstruction, and ED census and staffing levels.

In an associated editorial, Mark Malagoni (Case Western Reserve University, Cleveland, Ohio, USA) said: "We must continue to advocate for optimal patient care, whether it is by improving 'handoffs' in the emergency department, evaluating patients more quickly in consultation, or creating a fast track to operation."

By Ingrid Grasmo

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