Effect of day of the week on short- and long-term mortality after emergency general surgery.

BACKGROUND: The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality. METHODS: This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival. RESULTS: A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday. CONCLUSION: There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.

Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study.

BACKGROUND: The optimal perioperative use of intensive care unit (ICU) resources is not yet defined. We sought to determine the effect of ICU admission on perioperative (30 day) and long-term mortality. METHODS: This was an observational study of all surgical patients in Scotland during 2005-7 followed up until 2012. Patient, operative, and care process factors were extracted. The primary outcome was perioperative mortality; secondary outcomes were 1 and 4 yr mortality. Multivariable regression was used to construct a risk prediction model to allow standard-risk and high-risk groups to be defined based on deciles of predicted perioperative mortality risk, and to determine the effect of ICU admission (direct from theatre; indirect after initial care on ward; no ICU admission) on outcome adjusted for confounders. RESULTS: There were 572 598 patients included. The risk model performed well (c-index 0.92). Perioperative mortality occurred in 1125 (0.2%) in the standard-risk group (n=510 979) and in 3636 (6.4%) in the high-risk group (n=56 785). Patients with no ICU admission within 7 days of surgery had the lowest perioperative mortality (whole cohort 0.7%; high-risk cohort 5.3%). Indirect ICU admission was associated with a higher risk of perioperative mortality when compared with direct admission for the whole cohort (20.9 vs 12.1%; adjusted odds ratio 2.39, 95% confidence interval 2.01-2.84; P<0.01) and for high-risk patients (26.2 vs 17.8%; adjusted odds ratio 1.64, 95% confidence interval 1.37-1.96; P<0.01). Compared with direct ICU admission, indirectly admitted patients had higher severity of illness on admission, required more organ support, and had an increased duration of ICU stay. CONCLUSIONS: Indirect ICU admission was associated with increased mortality and increased requirement for organ support. TRIAL REGISTRATION: UKCRN registry no. 15761.

Anaphylaxis admissions to UK critical care units between 2005 and 2009.

Anaphylaxis is a life-threatening emergency that may necessitate admission to a critical care unit. There are no reports of the frequency of admission to critical care units for patients with anaphylaxis or indeed any description of their demographic characteristics or outcomes. We analysed all physician-diagnosed cases of anaphylaxis over a 5-year period in national audit data from critical care units across the UK. Over the period 2005-2009, there were 81 paediatric and 1269 adult admissions with anaphylaxis admitted to UK critical care units (0.1% of admissions to paediatric units and 0.3% of admissions to adult units). Absolute numbers in both children and adults rose year on year. There were comparable proportions of admissions in female and male children (female = 47% and male = 53%; rate ratios (RR) = 0.88, 95% CI 0.64-1.20), but a greater proportion of adult female admissions (female = 65% and male = 35%; RR = 1.83, 95% CI 1.68-1.99). Survival to unit discharge was 95% (77/81) for children, and survival to hospital discharge was 92% (1166/1269) for adults. Each UK critical care unit is likely to see at least one anaphylaxis case per year. The number of admissions has risen in both children and adults. Although admission ratios between the sexes were comparable in children, there was a female preponderance in adult life. Survival rates were high at over 90%.

Effect of socioeconomic deprivation and the appointment of Welfare Attorneys.

Most patients in intensive care unit (ICU) lack decision-making ability. The Adults with Incapacity (Scotland) Act 2000 allows someone to appoint a Welfare Attorney (WA) to act on their behalf should they lose capacity. Scotland has areas of major socioeconomic deprivation associated with lower life-expectancy and with a lack of knowledge about and consequently difficulty accessing services. The effect of socioeconomic deprivation on WA registration was investigated. A complete list of registered WAs was categorized by deprivation. The Public Guardian, Scotland indicated whether patients admitted to ICU at Glasgow Royal (April 2006-May 2009) had a WA registered. All Scottish ICU admissions (2004-2008) were categorized by deprivation. Twelve of 1152 ICU patients at Glasgow Royal had a WA. Of 165,997 WAs registered, 5984 were in the most deprived and 27,970 in the most affluent areas. Overall, 3.9% of the Scottish population had a WA (1.4% in the most, 6.5% in the least deprived population decile). In conclusion, the uptake of WAs was low, especially in deprived areas. The reasons could include a lack of knowledge, not anticipating the need for a WA or not being confident in the process. Any educational package needs to target the most socioeconomically disadvantaged.