Browsing by Author "Rodriguez, Rachel"

Now showing 1 - 2 of 2
  • Thumbnail Image
    Item
    Early or Late Gastrografin Challenge for the Non-Operative Management of Small Bowel Obstruction
    (2020-09-10) Holder, Erik; Murphy, Patrick; Meagher, Ashley; Rodriguez, Rachel
    Introduction: Gastrogafin (GG) challenge is becoming the standard of care for the non-operative management of adhesive small bowel obstruction (aSBO). Protocols vary in the timing of GG challenge from early (≤ 24 hours) to late (> 24 hours). Concerns remain regarding the safety of early GG due to inadequate stomach and bowel decompression raising fear of complication such as aspiration. Few studies have investigated the relationship between the timing of GG and patient outcomes, including time to OR, length of stay or complication rate. We hypothesized early GG challenge would be non-inferior to late GG challenge and would have shorter length of stay. Methods: A retrospective cohort study of 215 patients over two years (2018-2019) who underwent non-operative management of adhesive SBO. We stratified patients by timing of GG challenge, ≤ 24 hours (Early GG) or > 24hours (Late GG). Our primary outcome was success of GG challenge defined by discharge without an operation. Secondary outcomes included bowel resection, re-admission rate, hospital length of stay, and mortality. Our non-inferiority margin was 4%. We used the Chen Quasi-Exact method to determine confidence intervals for small sample sizes to determine non-inferiority. Continuous data was assessed by one-way ANOVA and categorical data with Fischer’s Exact test. Results: A total of 215 patients underwent planned non-operative management of adhesive SBO over the study period, of whom 102 received a GG challenge. Early GG was administered in 33 (32%), Late GG was administered in 79 (68%). There was no difference in age or gender, but more African Americans received Late GG (40% vs 15%, p = 0.01). The need for operative intervention was lowest in the early group, 6.1% compared to 17.7% in the late group. The difference of -11.6% [95% CI -22.9% - 3.3%] was non-inferior (p=0.03) but did not meet superiority. No patient receiving Early GG required bowel resection compared to 5 (35%) in the Late GG group (p = 0.45). Hospital length of stay was a median of 3 (IQR 2) for Early GG compared to 4 (IQR 8) for Late GG (p < 0.001). There was no difference in mortality, re-admission rates, ICU admission or ICU length of stay between groups. Conclusion: Early GG challenge (≤ 24 hours) is non-inferior to late GG challenge (> 24 hours) for the non-operative management of adhesive SBO. Patients who received early GG had a shorter length of stay, and no complications associated with early GG. Additionally, fewer patients who received early GG received a bowel resection, although this is not statistically significant. This indicates need for multi-center evaluation of GG administration and development of practice management guidelines for patients with adhesive SBO. We recommend early GG challenge to decrease the time for operative decision making and reduce length of stay. A prospective study comparing early versus late GG challenge is needed to determine optimal timing.
  • Thumbnail Image
    Item
    Impact of a Daytime Operating Room on Resource Use and Outcomes in Emergency General Surgery
    (2020-02-05) Murphy, Patrick; Patterson, Alicia; Holder, Erik; Scifres, Aaron; Rodriguez, Rachel
    Introduction: The implementation of acute care surgery (ACS) services has not been standardized. There is no known “best” model or optimal infrastructure required to care for emergency general surgery (EGS) patients. The addition of dedicated daytime operative room (OR) resources may increase patient access and reduce overnight operations. Methods: We performed a retrospective cohort study of patients who underwent emergency appendectomy, cholecystectomy, or hernia repair at a tertiary care center from Feb 1, 2015 to Dec 31, 2018. A daytime ACS room was implemented on Jan 18, 2017, dividing patients into two cohorts: the “Pre-Access” period prior to and “Post-Access” period after implementation. Resources were allocated to the ACS room only if cases were booked by 430 PM the day prior. Outcomes included after-hour ORs (5 pm – 7 am), time to OR, time of scheduled ORs (AM or PM) and relevant patient outcomes. Results: Over 4-years, 925 patients underwent appendectomy (42%), cholecystectomy (50%) or hernia repair (8%) on an emergent basis. There was a 49% increase in volume in the Post-Access period, without an increase in time to OR [14 h, IQR 38 for both groups], after-hours OR (42.1% v 42.1%, p=0.99) or timing of ORs (28.3% v 29.1% AM start and 29.4% v 28.7% PM start, p=0.96). There was no change in hospital length of stay [2 d, IQR 4 v 3 d, IQR 4, p=0.39] or complication rates (14% v 18%, p=0.15). On subgroup analysis, only delayed cholecystectomies for gallstone pancreatitis (GSP) showed a reduction in after-hours ORs (13% v 0%, p=0.03) and an increase in AM OR start times (43% v 71%, p=0.02), suggesting that pre-scheduled cases are most affected by this OR allocation model. Conclusion: Despite a significant increase in volume there was no increase in after-hours resource utilization, hospital length of stay, or worse patient outcomes. The addition of an ACS room improved daytime access for GSP but not for other diagnoses. Dedicated infrastructure results in efficient use of resources and the ability to manage increasing patient volumes. Efficiency may be further improved by dedicated staffing of ACS rooms.