The Provision Of Emergency Surgical Care Nursing Essay

Acute traumatic abdominal condition: An abdominal injury with evident trauma to the abdomen. Obvious signs of intra-abdominal injury may be present or absent. It is usually classified as penetrating or blunt abdominal trauma.

Penetrating abdominal injury: Occurs when an object pierces the abdominal wall and enters the abdominal cavity.

Blunt abdominal injury: Occurs when an object forcefully impacts on the abdominal wall but does not penetrate

In-patient hospital stay: From the time of admission to the time the patient is discharged by a doctor.

Wound dehiscence: This is an acute wound failure. It can be partial with the failure of only the skin and subcutaneous tissues or complete with failure of the rectus sheath and subsequent evisceration of abdominal contents. (A ‘burst abdomen’) The Provision Of Emergency Surgical Care Nursing Essay.

Wound sepsis:

Superficial surgical site infection – within 30 days of a surgical procedure, this infection involves only skin and subcutaneous tissue of the incision and patient has any or all of the following: purulent draining from the superficial incision or pain, tenderness, localized swelling, redness, heat at the incision site.

Deep surgical site infection – within 30 days of a surgical procedure, this infection involves only the fascial and muscle layers of the incision and the patient has any or all of the following: a purulent drainage from the deep incision or a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has any or all of the following signs or symptoms: fever (>38° C), or localized pain/ tenderness. (See Appendix 3)

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Mortality: From 24 hours post-operatively to the time an in-patient dies on the same admission and has been clinically certified by a doctor. The Provision Of Emergency Surgical Care Nursing Essay.

TABLE OF CONTENTS

Title page…………………………………………………………………………………….1

Declaration………………………………………………………………………………………………………….4

Acknowledgements………………………………………………………………………………………………5

List of Abbreviations…………………………………………………………………………………………….6

Definition of terms…………………………………………………………………………………7

Table of contents……………………………………………………………..………………8

Abstract……………………………………………………………………………………………………………..11

Chapter 1: Introduction……………………………………………………………………13

Chapter 2: Literature review……………………….……………………….…………..…14

2.1: Theatre delay/ Time interval………………………………………………………………………….14

2.2: Study Justification……………………………………………………………………………………….16

2.3: Study objectives………………………………………………………………………………….………17

Chapter 3: Materials and methods…………………………………………………………………….……18

Chapter 4: Results…………………………………………………………………………………………..……22

Chapter 5: Discussions………………………….………………………………………….36

Chapter 6: Conclusion………………………………………………………………………………….……….41

Chapter 7: Recommendations……………………………………………………………………………….42

References…………………………………………………………………………………………………………..43

List of Tables

Table 1 Age distribution of patients admitted to KNH with acute traumatic abdominal injuries…… 22

Table 2 Causes of abdominal injuries in patients admitted to KNH ……………………………………24

Table 3 Comparison of ASA scores with the time intervals……………………………………………. 25

Table 4 Comparison of the type of injury with positive and negative laparotomies…………………. 27

Table 5 Comparison of the number of patients with organ injury to the time interval……………… 28

Table 6 Preoperative time interval for traumatic abdominal injury admissions at KNH……………. 28

Table 7 Comparison of the time interval to the type and cause of injury…………………………….. 29

Table 8 Impact of the operative time interval on the median postoperative hospital stay………….. 30

Table 9 Comparison of the hospital stay to morbidity outcomes……………………………………… 30

Table 10 Comparison of morbidity outcomes according to preoperative time intervals…………….. 32

Table 11 Type of injury compared to morbidity outcomes……………………………………………… 32

Table 12 Comparison of morbidity outcomes in positive and negative laparotomies……………….. 33

Table 13 Comparison of the ASA score in morbidity outcomes and mortality………………………. 33

Table 14 Comparison of mortality outcomes according to preoperative time intervals………………. 35

List of Figures

Figure 1 Gender distribution of patients admitted with acute traumatic abdominal injuries in

KNH…………………………………………………………………………………………………………………… 23

Figure 2 Types of abdominal injuries among patients admitted to KNH…………………………………… 23

Figure 3 ASA scores for patients admitted to KNH with abdominal injuries…………………………….. 25

Figure 4 Operative findings in patients with abdominal injuries at KNH………………………………….. 26

Figure 5 Number of patients with specific abdominal organ injury………………………………………….. 27

Figure 6 prevalence of postoperative morbidity outcomes in patients with abdominal

injuries at KNH………………………………………………………………………………………………………31

Figure 7 Mortality rates of patients with abdominal injury at KNH………………………………………….. 35

Appendices

Appendix I Consent\ Kibali cha ruhusa……………………………………………………………..…46

Appendix II Standard Form………………………………………………………………………………56

Appendix III CDC definition of Nosocomial infections……………………………………………….. 57

Appendix IV KNH Ethical Approval……………………………………………………………………… 58

ABSTRACT

Background: The provision of emergency surgical care to patients with acute surgical abdominal conditions is one of the cornerstones of General Surgical Practice. As most interventions are time critical, the intra-hospital time interval between diagnosis and the actual operation influences the outcome in these patients. This time-interval can be modified, unlike other factors which also influence post-operative outcomes. This study sought to investigate the association between the time-to surgery and the patient’s outcome.

Objective: To determine the effect of the time interval on post-operative wound dehiscence, wound sepsis, length of hospital stay and mortality in patients with acute traumatic abdominal conditions at Kenyatta National Hospital. The Provision Of Emergency Surgical Care Nursing Essay.

Patients and methods: A prospective analysis of 73 consecutive patients presenting with acute traumatic abdominal surgical conditions at the Accident and Emergency Department, KNH, between December 2012 and April 2013, was conducted. The time interval between T1 (decision to operate) and T2 (induction of anesthesia) was recorded.

The main outcome measures were the in-patient hospital stay, wound dehiscence, wound sepsis and mortality. This follow-up was done in the general surgical and pediatric surgical wards. The data was collected using a standard form, entered and verified using Microsoft excel.

Analysis of the data collected was performed by Statistical Package for Social Sciences version 17 (SPSS 17.0) and graphs, pie-charts and tables were used to present the results.

Results: A total of 73 patients admitted to KNH with acute traumatic abdominal injuries were included in this study. The average age (SD) of the patients with abdominal injuries was 28 years (SD 8.8) and the age range was from 12 years to 51 years. The percentage of males presenting with abdominal injuries was 91.8% and this was significantly higher than that of female patients (8.2%), difference = 83.6% (95% CI 60.6-100), p < 0.001. Most (72.6%) patients presented with penetrating abdominal injuries and the remaining 27.4% presented with blunt abdominal injuries. The Provision Of Emergency Surgical Care Nursing Essay. Stab injuries were the most common cause of abdominal injury accounting for 56.2% of all admissions. RTA was the second most common cause of abdominal injury (26%). Other important causes of injuries were gunshot wounds (16.4%). 63% of all operations were

performed within 6 hours of presentation to KNH. Thirty percent of operations were performed between 7 and 12 hours of admission and the remaining 6.9% conducted 13-24 hours post-admission. The duration of inpatient stay ranged from 2 days to 49 days with a median length of stay of 7 days (IQR 6-9 days). The most common outcome was superficial SSI documented in 24 (32.9%) patients. Wound dehiscence and deep SSI occurred in 9.6% and 8.2% of patients, respectively. A total 4 deaths occurred among the 73 patients with abdominal injuries giving an overall mortality rate of 5.5%.

Comparison of post-operative hospital stay according to preoperative time interval showed that there was no statistically significant difference in median duration of stay among patients operated within 6 hours (median = 7 days), 7-12 hours (median = 7 days) or 13-24 hours (median = 8 days) post admission (Kruskall-Wallis p value = 0.88).

There were no significant differences in the percentage of patients with superficial SSI within the different pre-operative time intervals (35% versus 32% and 20%), p = 0.92. Similarly the occurrence of deep SSI (p = 0.46) and wound dehiscence (p = 0.41) was not significantly influenced by the pre-operative time interval.

Mortality rates reported in the groups of patients undergoing operation 0-6 hours and 7-12 hours after admission were 6.5% and 4.6% while no death occurred among the 5 patients operated 13-24 hours post admission (p = 0.99).The pre-operative time interval was not significantly associated with mortality. The Provision Of Emergency Surgical Care Nursing Essay.

Conclusion

In this study the time interval was not significantly associated with morbidity outcomes and mortality. The null hypothesis of the study was accepted.

The male predominance, the most affected age bracket of 20 to 29 years, the higher frequency of penetrating acute abdominal injuries compared to blunt abdominal injuries was consistent with other previous studies.

Chapter 1: INTRODUCTION

The provision of emergency surgical care to patients with acute surgical abdominal conditions is one of the cornerstones of General Surgical Practice. As most interventions are time critical, the time interval between diagnosis and the actual operation greatly influences the outcome in these patients. This time-interval can be modified, unlike other factors which also influence post-operative outcomes

Outcomes of surgical procedures are dependent on various factors including severity of surgical condition, pre-existing medical conditions, degree of contamination and time to surgery. It has been documented that longer delays in surgical treatment have adverse effects on post-operative outcomes.1

KNH is a busy teaching and referral hospital in Kenya. It is one of the two referral hospitals in the country, serving a large population of people. It is also a primary hospital for many of the people living in Nairobi and its environs, serving a wide catchment area.

Due to this wide catchment area, situations may arise where prompt access to theatre for emergency surgical operations may be difficult to achieve. For example, in the year 2011, the non-gynaecological, non-elective operations performed at KNH were 5933, with an average of almost 500 cases per month (KNH records). The hospital has one dedicated emergency theatre for general surgical procedures. The Provision Of Emergency Surgical Care Nursing Essay.

Data on time to surgery and associated outcomes in Kenya is hardly available, though a study was done on the effects of delayed treatment on perforated duodenal ulcers at KNH in 2009 2. This study will determine the impact of the intra-hospital time interval to surgery on the outcomes of patients with acute traumatic abdominal surgical conditions.

Chapter 2: LITERATURE REVIEW

Emergency surgery for traumatic and non- traumatic acute abdominal conditions presents a significant percent of the general surgery workload.1

Various studies have indicated that general surgery emergency admissions comprise the largest group of all surgical admissions at approximately 46% – 57% and account for a large percentage of all surgical deaths3-6. The largest component of the emergency general surgical case-mix is gastrointestinal 6 . Emergency major gastro-intestinal surgery has one of the highest mortalities which can reach 50% in those over 80 years7. Indeed, advanced age, co-morbid disease, and major and emergency surgery are key factors associated with higher risk of mortality. A prolonged time interval to surgery can be hazardous to a patient’s condition8.

Emergency laparotomies make up a considerable proportion of general surgical operations with some authors reporting as much as 66%9. Patients with acute abdominal conditions are often the sickest and can present with fairly challenging cases. The Provision Of Emergency Surgical Care Nursing Essay. After adequate resuscitation, they require prompt surgical intervention.

Preoperative resuscitation is one of the factors that may contribute to intra-hospital delay in treatment, but it allows both anaesthesia and surgery to be conducted safely as it prevents tissue hypo-perfusion which can lead to organ failure and increase the mortality rate as the number of organs failing increase 10.

However, at times, complete restitution of the circulatory volume and tissue perfusion may not be possible preoperatively. Using the NCEPOD definition of emergency surgery as an immediate life saving operation, resuscitation is done simultaneously with surgical treatment7.

2.1 Theatre delay/ time interval

Early presentation of cases to the hospital and prompt surgical treatment of the adequately resuscitated patient are crucial to the post operative survival of the patient 11. Staffing levels12, 13 and patient numbers 14-17 have been shown to be associated with the quality and timeliness of hospital and emergency department patient care. Prompt treatment depends on hospital resources as well as the clinical efficiency of the triad that make up the surgical team – the surgeon, the anaesthetist and the nursing staff. Access to theatre can be a major problem, indicating the importance of prioritising competing emergencies as well as a dedicated and fully staffed theatre.6

The aims of a dedicated theatre capacity are three-fold:

to reduce delays to theatre

to decrease out-of-hours operations

to prevent cancellation of elective patients18

Limitations of hospital resources may have serious consequences in the provision of an adequate emergency surgical service.9 Poorly delivered emergency surgical services increase costs in terms of complications, re-operation and increased length of hospital stay; to society in terms of rehabilitation costs and welfare support; to the patient in terms of poor quality of life, morbidity and mortality 19.

Delay in treating emergency surgical patients result in additional complications and higher mortality.20-24 Using appendicectomy as an illustration, surgery for uncomplicated (non-perforated) appendicitis has a mortality rate of 0.8/1000, but on perforation, the mortality rate increases by a factor of 6.25 Approximately 36 hours after the onset of symptoms, the mean perforation rate is between 16-36% and increases by 5% for every 12 hour delay to surgery.26-28 In a study by Mbah at Usmamu Danfodiyo, a Nigerian teaching hospital, it was noted that delayed presentation was common due to ignorance, poor roads, and poverty.29 They also noted that the intra-hospital time interval to surgery was prolonged due to both patient factors which included financial constraints and institutional inadequacies which included waiting for complementary investigations, inadequate theatre facilities and inadequate theatre staff. Greater than 90% of emergency laparotomies were delayed by 6 hours or more.The Provision Of Emergency Surgical Care Nursing Essay.  They noted that the morbidity and mortality were more in patients operated after 6hrs.

A study by Adamu 30 from Zaria, Nigeria also had similar findings. In addition, they noted that the time interval to surgery was an independent determinant of mortality and the extent of morbidity.

Similar studies in other surgical specialities- plastic surgery, neurosurgery and orthopaedic surgery, have shown that delays in operation make the outcome more unfavourable.18,31,32

In their study Wyatt, defined ‘Theatre delay’ as any factor contributing towards a delay in operating on an emergency general surgical patient following the surgeon’s decision to operate and his contacting the operating theatre.9They reported a median delay of 3 hours for all patients, with 88% having a time interval of more than 1 hour and 15% having a delay of more than 6 hours. During the normal working hours (9a.m to 5p.m- weekdays), the median delay was 5 hours. In all the other time periods, including weekends, the median delay was 2 to 3 hours. Theatre unavailability due to other operational procedures was reported to be 30%; nurse, porter and theatre assistant unavailability was 17%; anaesthetic delay was 30%; ward delay was 4% and in 18%, no delay was recorded. They noted that an unacceptable number of emergencies were

conducted late in the night due to evening theatre delays. Consequently, standards of care may have been compromised as few senior staff members were available.

A study in Pakistan by Jawaid, reported that 36% of theatre delays were caused by poor staff commitment and inefficiency of the surgical team33 A prospective study at KNH in 1991 by Ngugi34 reported that theatre delay was primarily due to unavailability of theatre or blood and shortage of theatre staff. Then (as now), there was only one fully dedicated emergency theatre for all surgical emergencies. The time interval (Average hospital stay in brackets) for uncomplicated appendicitis was 7.24h (3.42d), complicated appendicitis was 12.66h (6.8d), abdominal trauma was 11.02h (10.92d), strangulated inguinal hernia was 6h (8d) and intestinal obstruction due to sigmoid volvulus was 11.4h (12.7d). The average theatre delay for the study was 21.7h. Another prospective study in 2006 by Musau35 on the “pattern and outcome of abdominal injury at KNH” found that 46% of patients were operated on within 6 hours of admission. The Provision Of Emergency Surgical Care Nursing Essay. He also noted that 76% of patients were operated on within the first 12 hours of admission. In a study with both prospective and retrospective arms, done at KNH in 2009 on the “effects of delayed treatment on perforated peptic ulcers”, Nasio and Saidi2 found that 74% of patients were operated within 24 hours with a mean delay of 21.7 hours. The morbidity and mortality was higher in those patients who had longer pre-hospital and intra-hospital delays to treatment.

2.2 Justification of the study

Time to surgery influences the patient’s outcome as has been documented in various studies. The demand for emergency surgical services is high at Kenyatta National Hospital and this necessitates the sharing of the limited emergency theatres between the different surgical units resulting in potential delays.

Discussions with many colleagues across the different surgical specialities, albeit anecdotal, have indicated that the time interval to surgery is often prolonged and perhaps detrimental to the patient, both physiologically and psychologically, yet there is little evidence to support this.

The aim of this study is therefore to document the impact of the time interval from the decision to operate to anaesthetic induction on the outcomes of patients with acute traumatic abdominal conditions. The findings may form in future a useful basis of developing guidelines for surgical interventions for patients with acute traumatic surgical abdominal conditions and serve as a template for further research.

2.3 Objectives of the Study

Broad Objective:

To determine the impact of the time interval, from the decision to operate, to induction of anaesthesia, on outcomes in adults with acute traumatic abdominal conditions.

Specific objectives:

To determine the impact of the pre –operative time interval on post-operative hospital stay among patients with acute traumatic abdominal conditions.

To determine the morbidity and mortality rates that may be associated with the time interval from the decision to operate and anaesthesia induction, including rates of wound dehiscence and wound sepsis.

Null Hypothesis:

Time to surgery does not influence the outcome in adults with acute traumatic abdominal conditions

Chapter 3 MATERIAL AND METHODS

3.1 Study Design and Period -This was a hospital based, single centre prospective cross-sectional study carried out between December 2012 and April 2013.

3.2 Study Setting – This was conducted at the Kenyatta National Hospital (KNH) Accident and Emergency department, general and paediatric surgical wards and operating theatres. The Provision Of Emergency Surgical Care Nursing Essay.

3.3 Study population – These were patients (between 12 – 60 years) presenting with acute traumatic surgical abdominal conditions at KNH casualty and the wards. Participants who met the inclusion criteria were selected consecutively until sample size was achieved.

3.4 Methodology:

The proposal was presented to the University of Nairobi department of surgery and approval was then sought from the ERC. The principal investigator then collected data from a consenting patient, in whom a diagnosis of an acute traumatic surgical abdominal condition requiring a laparotomy had been made. The information was recorded in a standard form (Appendix 2). The consent was signed at first contact at the Accident and Emergency department.

The principal investigator recorded the demographic details of each patient, the time when a decision was made to operate, the time when the operation began and ASA score (these were derived from the anaesthetic chart, the time groups, types and causes of the abdominal injuries, associated injuries, co morbidities, peritoneal contamination, operational findings.

Data was also collected while the patient was in the ward, on inpatient hospital stay, presence or absence of wound sepsis, wound dehiscence and finally, mortality. Patients were followed up to the date of discharge or death, by the principal investigator.

3.5 Patients

Inclusion Criteria

Patients, between 12 to 60 years, who had acute traumatic surgical abdominal conditions. The Provision Of Emergency Surgical Care Nursing Essay. The surgeon would have made a decision to proceed with a laparotomy and the patients would have signed an informed study consent form.

Exclusion Criteria

Patients with acute traumatic surgical abdominal conditions who had been admitted for observation or a decision had not been made to operate.

Patients who had non-traumatic acute surgical abdominal conditions.

Patients who had not signed the study consent form.

3.6 Sampling technique:

All consecutive patients diagnosed with acute traumatic abdominal injury at casualty were recruited through convenient sampling method.

Sample size calculation:

Using the Fisher’s formula35

n= z2pq/d2

Where,

n = minimum sample size

z = units of standard normal deviation corresponding to 95% confidence interval (usually 1.96)

p= prevalence of the characteristic being studied- abdominal injury (Musau used 5% in his study35)

q= prevalence of the population without the characteristic being studied (1-p)

d= error margin (usually 5/100), which is 0.05.

.

n= 1.962 x 0.05x 0.95/ 0.0025

n= 72.99

So n was rounded to 73 patients.

3.7 Data analysis and presentation

Data collected was entered into a password protected Microsoft access database and patient files kept in a lockable cabinet accessible only to the principal investigator and the statistician. Accuracy was ensured by comparing the data entries in the standard forms and the soft copy. Analysis was performed using Statistical Package for Social Sciences version 17.0 (SPSS 17.0).

Continuous variables such as age were summarised using measures of central tendency and dispersions – mean, median, range, and standard deviation.

Categorical variables, for example, the comparison of the time interval groups versus arising complications were analysed using Fischer exact tests due to the small sample sizes. The variables that did not assume a normal distribution were analyzed using the non-parametric statistical test – Kruskall Wallis, which was used for univariate analysis of continuous variables when comparing 3 or more independent groups.

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All the p-values were 2-tailed with the significance level set at 0.05.

The results were presented in the form of tables, figures and pie-charts.

3.8 Ethical considerations

Approval to carry out the study was sought from the Department of surgery, University of Nairobi and Kenyatta National Hospital Ethics and Research Committee.

Patients were recruited into the study at first contact, either in casualty or in the ward, and were requested to sign consent after a clear explanation of the nature and purpose of the study. Parents or Guardians were requested to sign consent forms for patients aged 12 to 17 years; these patients were also to sign an Assent form for minors. Patients who declined to consent did not have their treatment jeopardized in any way. All information obtained was treated confidentially.

Data collected was to be destroyed upon completion of the dissertation. The Provision Of Emergency Surgical Care Nursing Essay.

3.9 Study limitations

The representativeness of the results from this study might have been affected by the non-probability sampling technique that was used.

As the study was done in a single institution setting, the results may not be generalised to other settings.

It was difficult to control for all other factors (confounders) that affect surgical outcomes such as immunosuppression, nutrition, delay in seeking medical care, wound contamination etc.

There were many factors which contributed to the surgical patient’s morbidity and mortality and consequently it was difficult to wholly attribute the outcome to the time interval. The Provision Of Emergency Surgical Care Nursing Essay.