A Closed Loop Audit on the Management of Acute Cholecystitis During the Covid-19 Pandemic

ABSTRACT

Background: The definitive management of acute cholecystitis is laparoscopic cholecystectomy on the same admission, if the patient is fit. However, as the Covid-19 pandemic emerged, evidence suggested adverse outcomes for asymptomatic Covid positive patients undergoing surgery, including increased mortality risk. Risks to theatre staff were also highlighted. This prompted changes in guidelines produced by the Association of Upper Gastrointestinal Surgeons (AUGIS) in March 2020, which strongly supported the conservative non-surgical management of acute cholecystitis. Method(s) This closed loop audit aimed to establish whether patients with acute cholecystitis were managed in accordance with AUGIS guideline changes at our hospital. It also aimed to assess the clinical outcomes of the guideline changes. This retrospective audit focused on patient admissions with acute cholecystitis at our hospital during the 2 peaks of the Covid-19 pandemic. The timeframe of the initial audit was 17th April - 14th May 2020 (4 weeks). The timeframe of the re-audit was 1st - 28th February 2021 (4 weeks). Handover sheets and clinical software were the data sources. The initial audit was presented at the General Surgery departmental clinical governance meeting in September 2020 and formed the educational intervention. Result(s) 24 patients with acute cholecystitis were included in the initial audit, and 25 patients in the re-audit. The initial audit found that 15 patients (62.5%) with acute cholecystitis were managed conservatively with IV antibiotics, 4 patients (16.6%) had a percutaneous cholecystostomy, and 5 patients (20.8%) underwent laparoscopic cholecystectomy during their index admission. Following our educational intervention, the re-audit found that 22 patients (88%) were treated conservatively, 1 patient (4%) had a percutaneous cholecystostomy, and 2 patients (8%) underwent laparoscopic cholecystectomy. The mean length of hospital stay reduced from 5.67 days in the initial audit, to 3.88 days in the re-audit. 30 day readmission rates also reduced from 5 patients (20.8%) to 0 patients (0%). 2 patients aged >60 years died from unrelated causes during their index admission. They had Charlson Comorbidity Index scores >2. Conclusion(s) Management of acute cholecystitis was more compliant with AUGIS guidelines following the educational intervention. Importantly, overall, conservative non-surgical management did not clinically disadvantage patients, and was not associated with the development of complications of acute cholecystitis, such as gallbladder empyema or perforation. Indeed, the re-audit revealed shorter length of hospital stay and lower 30 day readmission rate than the initial audit. For vulnerable patients at risk of serious complications from contracting Covid-19, this certainly had positive implications for wellbeing, reducing exposure to the hospital environment. There were also further beneficial implications for limited bed resources. Our findings, however, suggest that flexibility is required in decision-making in the management of acute cholecystitis. In carefully selected patients, for example younger patients with fewer comorbidities, emergency laparoscopic cholecystectomy might avoid future readmission with serious complications of gallstones, such as ascending cholangitis and pancreatitis. The evidence from our local audit suggests that AUGIS guideline changes may overall benefit and improve the clinical outcomes of patients with acute cholecystitis. However, decisions about management should be in the interests of, and tailored to, the individual patient.