Improving the assessment process for patients presenting with acute (non-traumatic) abdominal pain to the general surgery department.

Abstract

Background Abdominal pain is a very common but also challenging presentation to general surgery. A number of implementations have been introduced to improve the diagnostic process. These include: ED 4-6 hour targets, acute surgical admission units and better access to additional imaging (mainly CT scan). Regardless of these implementations, there seems to be ongoing inefficiency within the diagnostic process, with subjective observation of long transit times between presentation and start of treatment. Improving the diagnostic process and the use of imaging for this patient group will result in better use of hospital resources and improved patient care. Section 1 Aim To evaluate the current process of how patients presenting with abdominal pain to the general surgery department are assessed. Methods This section consists of 4 separate studies evaluating the number of admissions, diagnoses, the use of imaging and access to theatre. Conclusion Over the last decade a significant increase was seen in the number of patients admitted with a non-surgical diagnosis (constipation, gastroenteritis and non-specific abdominal pain). Also, CT scans were performed more frequently. This did, however, not affect the negative appendicectomy rate. Furthermore, according to an expert panel, approximately one-fifth of the scans was considered not indicated. These findings highlighted the areas for improvement in the diagnostic process for patients presenting with acute abdominal pain. Section 2 Aim To identify the current evidence of diagnostic pathways for patients presenting acutely with abdominal pain. Methods A systematic review was performed including all studies that described an algorithm for assessing patients presenting with acute, nontraumatic, abdominal pain Conclusion The systematic review found that 10 studies described a diagnostic pathway for diagnosing patients with abdominal pain. All pathways supported routine imaging (ultrasound and/or CT scan). However, none of the studies reported a reduction in complication rate, mortality or length of stay. Section 3 Aim The first step in this section was to identify whether registrars could accurately identify the urgent from the non-urgent patient presenting with abdominal pain. The second step was the implementation of a quality improvement initiative aiming to encourage early discharge for patients presenting with non-surgical abdominal pain and to reduce use of imaging for this patient group. Methods This section contains of two prospective cohort studies. Conclusion The first step showed that registrars could accurately identify the urgent from the non-urgent patient presenting with abdominal pain. This enabled us to introduce the second step, which was the implementation of a quality improvement initiative. In this study a significant increase in early discharges for patients presenting with non-surgical abdominal pain was observed and the use of imaging for this patient group significantly decreased. Representation and complication rates remained unchanged. Overall conclusions This PhD highlights the problems in the assessment process for patients presenting with abdominal pain. When the assessment process can be optimised by implementing the quality improvement initiative,limited health care resources are used more wisely. This has obvious cost implications, but should also result in increased focus on patients with acute surgical pathology and improve their outcomes.