Two years of Acute Biliary Admissions at a tertiary care centre over the Covid-19 pandemic: a closed loop audit with implementation of an acute referral system

ABSTRACT

Background AUGIS recommends patients diagnosed with acute cholecystitis and gallstone pancreatitis to receive a laparoscopy cholecystectomy on the index admission, ideally within 72 hours of presentation. Early laparoscopic cholecystectomy is associated with better patient outcomes and reduced readmission rates. During the Covid-19 pandemic emergency surgery, if possible was avoided. These patients are referred for an elective cholecystectomy, however waiting times can be lengthy with readmissions common prior to surgery.  Methods We performed a closed loop audit on acute biliary admissions to a central London tertiary care centre. We assessed waiting times to laparoscopic cholecystectomy for patients fit for surgery as well as readmissions prior to surgery. The data was collated over a one-year period (01/03/2019 to 29/02/2020), analysed and presented to the senior biliary surgery team. A dedicated e-referral system for patients who did not receive a laparoscopic cholecystectomy on index admission was implemented. Post intervention admissions were re-audited over a second year (01/03/2020- 30/01/2021) and re-analysed to assess the effect of the intervention.   Results A total of 111 patients with acute cholecystitis, 52 with gallstone pancreatitis, 34 with biliary colic, 36 with choledocholithiasis and 10 with ascending cholangitis, were included. Prior to implementation of our referral system average waiting time to laparoscopic cholecystectomy was 98.2 weeks, reduced to 47.7 weeks post referral system implementation. Reduction in waiting times resulted in readmission rates reduced by 23.3% in Choledocholithiasis;17.4% in Biliary Colic;  16.7% in Ascending Cholangitis;12.8% in Acute Cholecystitis and 8.3% in Gallstone pancreatitis.  Conclusions Admissions with acute biliary colic compose a substantial workload. The COVID-19 pandemic has resulted in a preference for elective versus emergency laparoscopic cholecystectomy. However, delay in surgery results in a readmission burden on emergency surgery departments and worse patient outcomes hence laparoscopic cholecystectomy should be performed as soon as possible following initial admission. This audit demonstrates that a dedicated biliary referral system reduced waiting time which translates to a reduction in admission rates. The importance of this referral system is magnified in the recovery phase of the pandemic where we continue to recover waiting times.