Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study.

OBJECTIVES: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. STUDY DESIGN: Single-centre qualitative study. METHODS: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. RESULTS: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. CONCLUSION: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care.

The nursing and financial implications of laparoscopic colorectal surgery: data from a randomized controlled trial.

AIM: The issue of cost effectiveness of laparoscopic surgery remains uncertain and its impact on the ward nursing staff is unaddressed. This study investigated these issues using patients from a single centre admitted to a randomized controlled trial. METHOD: All patients recruited into the Australasian Laparoscopic Colon Cancer Study (ALCCaS) from The Queen Elizabeth Hospital between January 1999 and March 2005 were included in this study. Data relating to hospital cost were collated from the Hospital Patient Costing System. Nursing interventions were calculated in minutes per patient, using the excelcare Software database. RESULTS: Data from 97 patients were analysed (laparoscopy, 53; open surgery, 44). The median number of hours of nursing input per patient was 80 (27.5-907) h in the open surgery group and 58.5 (15-684.5) h in the laparoscopy group. This difference was further increased after exclusion of patients converted from laparoscopy to open surgery. The median total cost of the procedure was AUS $9698/£ 5631 (AUS $3862-90,397) in the open surgery group and AUS $10,951/£ 6219 (AUS$2337-66,237) in the laparoscopy group. CONCLUSION: These data suggest that laparoscopic colorectal surgery is equivalent in price to open surgery and there may be added benefits in reduced nursing intensity.

Lymph node retrieval in colorectal cancer resection specimens: national standards are achievable, and low numbers are associated with reduced survival.

OBJECTIVES: The current guidelines identify the retrieval of at least 12 lymph nodes as crucial for accurate staging of colorectal cancer. We set out to review our figures from a single centre to see whether this standard has been met, and to examine for factors which may influence the number of lymph nodes retrieved. The influence of a low lymph node harvest on survival in patients with Dukes' A and B cancers was specifically investigated. METHOD: Data were collected from all patients with colorectal cancer undergoing resectional surgery from our prospectively compiled database between June 1998 and May 2007. A multivariate analysis was performed to identify factors resulting in low lymph node yields in those patients undergoing formal resection. Survival analyses were performed in patients with Dukes' A and B cancers to assess whether a low lymph node yield negatively impacted on survival. RESULTS: A total of 2449 patients underwent formal resection and were included in the analysis. The median lymph node retrieval was 13 nodes (range 0-136). On multivariate analysis, preoperative chemo-radiotherapy, operation type, specimen length and patient age all independently influenced lymph node retrieval. Patient gender, ethnicity, operative mode, operative team and consultant presence had no influence. Survival in patients with Dukes' A and B cancers was significantly reduced if <12 nodes were sampled. CONCLUSIONS: As a unit, we are achieving the national standard for lymph node harvest. This standard was maintained whether the surgeon performing the surgery was a consultant or a trainee, and also when the surgery was performed in the emergency setting. These data support the concept of 12 nodes being required for accurate staging.

Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer.

OBJECTIVE: Nonresectional palliative abdominal surgery (e.g. defunctioning stoma/bypass) may be appropriate for patients unsuitable for curative resection, to deal with complications of advanced colorectal malignancy such as obstruction. Our aim was to review the outcome of surgery in these patients within our institution. METHOD: All patients undergoing palliative surgery without resection for colorectal carcinoma between July 1998 and January 2007 were identified from our prospectively compiled colorectal cancer database. Data were extracted related to patients' demographics, presentation, tumour site, operative intervention, complications, oncological therapies, length of hospital stay and postoperative survival. RESULTS: One hundred and ninety-three patients were identified with a median age of 79 years (31-94 years). Fifty per cent were operated on an emergent basis for obstruction or perforation, and 50% on an elective basis. One hundred and sixty-nine patients had defunctioning stomas formed of which 156 were loop stomas. Twenty-four patients underwent bypass procedures. Thirty-day mortality rate was 13.5% and postoperative morbidity rate 47%. Median survival was 247 days, with 1-year survival of 38%. Patients undergoing operation on an emergent basis had poorer long-term survival (127 vs 320 days, P = 0.002). CONCLUSION: Nonresectional palliative abdominal surgery is associated with relatively high morbidity and mortality, particularly when performed in the emergency setting. However, in this patient group with a very poor outlook, it may be offered with reasonable survival expectations.

Colorectal cancer: presentation and outcome in British South Asians.

AIM: Colorectal cancer (CRC) has a lower incidence in patients of South Asian origin compared with British Caucasians. There are however little data available regarding the demographics of these patients, their presentation and outcome. Leicester has a high South Asian immigrant population, and we aim to define any potential differences in presentation, pathogenesis and outcome between our Caucasian and South Asian ethnic groups. METHOD: All patients of South Asian origin were identified from the Leicester CRC database between June 1998 and April 2007. Data were analysed regarding the patients' demographics, the presentation and treatment details, tumour characteristics and clinical outcome. Data were compared with Caucasian patients from the same database. Patients from an ethnic background other than South Asia or Caucasians were excluded from analysis. RESULTS: 3435 patients were included in the analysis, of which 134 (3.9%) were of South Asian ethnicity. 61.9% of South Asian patients were male compared with 56% of Caucasians. South Asians were significantly younger at presentation (61.4 vs 70.6 years, P < 0.001). South Asian patients had significantly more rectal tumours than their Caucasian counterparts (P = 0.002). South Asian patients were more likely to require initial oncological therapy, and were less likely to have resectional surgery than Caucasians (P = 0.006). Of the patients undergoing resectional surgery, the ASA grade, mode of surgery, tumour characteristics and Dukes' stage were similar. There was no difference in 5-year survival between the South Asian and Caucasian patients. CONCLUSION: Patients of South Asian ethnicity are younger at their age of presentation and have a higher proportion of rectal tumours compared with British Caucasian patients. They are more likely to require initial oncological treatment and are less likely to undergo resectional surgery, therefore suggesting more advanced disease at presentation. Overall 5-year survival is the similar.

Restorative proctocolectomy. Does ethnicity affect outcome?

OBJECTIVE: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is well-established in the management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We review outcome of pouch surgery from a single centre, comparing non-South Asian and South Asian Caucasian populations. METHOD: Patients undergoing RPC for UC and FAP during a 10-year period between January 1997 and January 2007 were identified from hospital records. Data were collected retrospectively from case notes on early and long-term results. RESULTS: A total of 107 patients underwent pouch formation for UC (94%) or FAP (6%) and 22 (21%) were from the Asian subcontinent. Eighty-seven (81%) underwent a three-stage procedure and 20 (19%) a two-stage procedure. Postoperative complications occurred in 40 (37%) patients, being major in 11 (10%) patients with relaparotomy required in 9 (8%) with no difference between South Asian and non-South Asian Caucasian patients. Long-term pouch function, with a median of five times over 24 h (range 2-15), was similar between the two groups. The incidence of pouchitis was 57 (53%) and this was significantly greater in the South Asian population [17/21 (77%); 39/86 (46%); P = 0.006]. CONCLUSION: Surgical results were similar in South Asian and non-South Asian Caucasian patients, but the incidence of pouchitis was greater in the former group.

An inguinal hernia of a third kind?

Inguinal hernias are classified anatomically into indirect and direct types. We illustrate two cases of an inguinal hernia where the defect was demonstrated to lie between the deep ring and the inferior epigastric vessels, therefore, not fitting the standard criteria for either direct or indirect inguinal hernias. Taking this into account, we propose that the hernia which we describe should either be considered as a completely new type of inguinal hernia or, alternatively, all of the currently accepted classifications should be changed or adapted to incorporate it.

Endovascular abdominal aortic aneurysm repair.

The operative mortality following conventional abdominal aortic aneurysm (AAA) repair has not fallen significantly over the past two decades. Since its inception in 1991, endovascular aneurysm repair (EVAR) has provided an alternative to open AAA repair and perhaps an opportunity to improve operative mortality. Two recent large randomised trials have demonstrated the short and medium term benefit of EVAR over open AAA repair, although data on the long term efficacy of the technique are still lacking. This review aimed at providing an overview of EVAR and a discussion of the potential benefits and current limitations of the technique.

Consumption of mannan-binding lectin during abdominal aortic aneurysm repair.

OBJECTIVE: Patients undergoing abdominal aortic aneurysm (AAA) repair are exposed to an ischaemia-reperfusion injury (IRI), which is in part mediated by complement activation. We investigated the role of the novel lectin pathway of complement during IRI in patients undergoing AAA repair. METHODS: Patients undergoing elective open infrarenal AAA repair had systemic blood samples taken at induction of anaesthesia, prior to aortic clamping, prior to aortic declamping and at reperfusion. Control patients undergoing major abdominal surgery were also included. Plasma was assayed for levels of mannan-binding lectin (MBL) using ELISA techniques. Consumption of plasma MBL was used as a measure of lectin pathway activation. RESULTS: Twenty-three patients undergoing AAA repair and eight control patients were recruited. No lectin pathway activation could be demonstrated in the control patients. AAA patients experienced a mean decrease in plasma MBL levels of 41% representing significant lectin pathway activation (p = 0.003). CONCLUSION: Consumption of MBL occurs during AAA repair, suggesting an important role for the lectin pathway in IRI. Specific transient inhibition of lectin pathway activity could be of significant therapeutic value in patients undergoing open surgical AAA repair.

Acute colonic pseudo-obstruction following major orthopaedic surgery.

OBJECTIVE: Acute colonic pseudo-obstruction (ACPO) has been linked with multiple aetiologies including orthopaedic surgery. However, the actual incidence and natural progression are not well described in these patients. We aim to assess the incidence of ACPO in patients undergoing elective orthopaedic procedures, and to examine for potential exacerbating factors. PATIENTS AND METHODS: All patients from the orthopaedic directorate that had abdominal imaging in the five years from August 1998 to August 2003 were identified from radiology archives. A manual search of the patients' notes was conducted with data recorded on the patients' history, operative details and their postoperative course including their haematological and biochemical results. Details regarding their ACPO were documented with respect to the onset of symptoms, how the diagnosis was achieved, what treatment was instigated and how the condition progressed. A control group of age and sex matched patients was included for comparison. RESULTS: Thirty-five patients with ACPO were identified. The operations included 21 hip replacements, 10 knee replacements and 4 spinal operations. The incidence of ACPO was 1.3%, 0.65% and 1.19%, respectively. In comparison to control patients, patients with ACPO had a lower postoperative serum sodium (P = 0.001), a higher serum urea (P = 0.021) and remained in hospital longer (P < 0.001). CONCLUSION: ACPO is uncommon in orthopaedic patients, however, its occurrence results in prolonged hospital stay. Attention to patients' postoperative fluid balance and biochemical status may reduce the incidence.

Urinary albumin:creatinine ratio (ACR) and the prediction of postoperative complications after abdominal aortic aneurysm repair.

INTRODUCTION: Open repair of abdominal aortic aneurysm (AAA) requires aortic clamping. This results in an ischaemia-reperfusion injury (IRI) which can lead to the development of the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF). We investigated the use of urinary albumin:creatinine ratio (ACR) as a simple predictor of the development of complications (SIRS) postoperatively. METHODS: Forty-four patients undergoing elective infrarenal AAA repair and 10 control patients undergoing major abdominal surgery had fresh urine samples taken before, immediately after and 24 h after the procedure. Urinary ACR was calculated on all samples, and daily SIRS scores were calculated for all patients postoperatively. Systemic interleukin-6 (IL-6) levels were measured intraoperatively to measure the cytokine response to surgery. RESULTS: AAA patients demonstrated a characteristic pattern of ACR levels during the three time points, with a significant increase in the ACR immediately postoperatively and with normalisation by 24 h (P<0.001 Wilcoxon signed ranks test). In comparison, control patients did not demonstrate any changes in their ACR (P=0.45 Wilcoxon signed ranks test) suggesting the increased ACR in AAA patients to occur as a result of IRI. ACR did not correlate with the development of SIRS postoperatively or with the systemic IL-6 response. CONCLUSIONS: Infrarenal AAA repair is associated with a temporary and reversible renal injury. ACR could not, however, be used as a predictor of complications postoperatively.

The management of abdominal aortic aneurysms in patients with concurrent renal impairment.

INTRODUCTION: Patients with concurrent renal impairment and abdominal aortic aneurysms present a significant challenge in terms of pre-operative, intra-operative and post-operative management. This aim of this review was to determine the risks of surgery in this patient group and determine whether any clear management strategies exist to enhance their clinical management. METHODS: Systematic review of published literature giving details of the outcome of open or endovascular abdominal aortic aneurysm repair in patients with pre-operative renal impairment. Papers concerning the management of post-operative acute renal failure in patients with normal pre-operative renal function has not been included. RESULTS: There is little data regarding patients with end-stage renal failure and AAA although these patients appear to have a high peri-operative mortality rate. In contrast, those with renal impairment do not have a significantly higher mortality rate than those with normal renal function, rather they have a higher risk of complications associated with surgery and may require more intensive post-operative organ system support than normal patients. Many have a transient deterioration in renal function in the immediate peri-operative period that will resolve. In the case of patients with ruptured AAA, it is not clear whether pre-operative renal impairment affects mortality.

Unreasonable expectations in emergency colorectal cancer surgery.

OBJECTIVES: The recently published ACPGBI colorectal cancer (ACPGBI CRC) scoring system for predicting operative mortality has been suggested as an instrument to improve patient consent procedures and to compare results between centres. This study compares the results of a surgical unit against the standards set by the ACPGBI colorectal cancer model and for emergency surgery, against the p-POSSUM instrument. METHODS: Data for the ACPGBI CRC model were collected prospectively through 2003 at the Leicester Royal Infirmary. Additional data needed for the p-POSSUM was retrospectively collected from case records. The actual mortality was compared with that predicted by the models. RESULTS: Seventy-two colorectal cancer operations were performed during the study period. The observed operative mortality in elective cases was lower, and in emergency cases higher, than predicted by the ACPGBI CRC model. With emergency cases the predicted mortality using P-POSSUM was significantly higher than that using the ACPGBI CRC model, particularly in the presence of faecal contamination. CONCLUSION: The ACPGBI CRC model may be accurate for elective cases, but appears to significantly underestimate predicted mortality in the emergency setting, both actual and predicted by p-POSSUM. This may be due to a failure to incorporate adequate weighting for faecal peritonitis and the associated systemic insult into the ACPGBI model.

Neutrophil activation occurs in the lower-limbs of patients undergoing elective repair of abdominal aortic aneurysm.

OBJECTIVES: AAA repair is associated with a systemic inflammatory response, mediated in part by neutrophils. The aim of this study was to determine where neutrophil activation occurs. METHODS: Blood was sampled from the femoral vein, portal vein and radial artery of 10 patients undergoing elective AAA repair at four time-points [induction of anaesthesia (systemic sample only), pre-aortic clamp application, pre-clamp removal and after 30min of reperfusion]. Whole blood was analysed for the white cell count, neutrophil count, and for neutrophil CD11b expression. RESULTS: The white cell count and neutrophil counts increased after aortic clamp release. Neutrophil expression of CD11b was significantly higher in the femoral vein than the portal vein and systemic circulation during ischaemia [P=0.001 (FV vs. PV), P=0.017 (FV vs. systemic)] and reperfusion [P=0.001 (FV vs. PV), P=0.013 (FV vs. systemic)]. There were no significant differences in neutrophil CD11b expression between the systemic and portal vein samples at any time. CONCLUSIONS: Ischaemia and reperfusion during abdominal aortic aneurysm repair are associated with a global increase in the white cell count and neutrophil count, but with increased neutrophil CD11b expression only in the femoral vein. This suggests the lower-limbs are sensitive to aortic clamp-related reperfusion injury and may fuel the inflammatory response.

Patients with abdominal aortic aneurysm: are we missing the opportunity for cardiovascular risk reduction?

INTRODUCTION: Antiplatelet agents, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statin drugs), angiotensin converting enzyme (ACE) inhibitors, and beta-adrenergic receptor blockers (beta-blockers) reduce cardiovascular risk and mortality in patients with specific manifestations of cardiovascular disease and risk factors. Occlusive arterial disease, in particular, coronary heart disease, is prevalent in patients with abdominal aortic aneurysm (AAA) and results in reduced life expectancy. The purpose of this study was to investigate the prevalence of cardiovascular disease and risk factors in patients with AAA. In particular, numbers of patients in whom pharmacologic therapy is indicated and numbers of patients who are receiving adequate treatment were determined. METHODS: This was a prospective study of 313 patients with AAA in Leicestershire over the 15 months between September 2002 and December 2003. RESULTS: Data that enabled determination of an indication for antiplatelet agents and statin drugs were available for 262 patients (84%), and for a beta-blocker and ACE inhibitor for 313 patients (100%). An antiplatelet agent was indicated in 242 of 262 patients (92%), a statin drug was indicated in 196 of 262 patients (75%), a beta-blocker was indicated in 107 of 313 patients (34%), and an ACE inhibitor was indicated in 178 of 313 patients (57%). In patients with an indication, 146 of 242 patients (60%) were using an antiplatelet agent, 81 of 196 (41%) were using a statin drug, 41 of 313 (38%) were using a beta-blocker, and 69 of 313 (39%) were using an ACE inhibitor. CONCLUSION: Cardiovascular disease, for which there is evidence for the survival benefit of pharmacologic risk reduction, is prevalent in patients with AAA. The data show that current treatment of cardiovascular risk is suboptimal and could be improved, with an expected reduction in cardiovascular morbidity and mortality.

The Surgical Acute Care Unit (SACU): effects on surgical workload and mortality.

BACKGROUND: A surgical acute care unit (SACU) is designed to provide level 1 care for surgical patients. The aim of the present study was to audit the effects of the introduction of a SACU in a teaching hospital surgical department. METHODS: A retrospective case-note audit of all admissions to the newly established SACU over the first 6 months was performed. Expected mortality and morbidity was calculated using POSSUM (physiological and operative severity score for the enumeration of mortality and morbidity) scores. Critical care data for the same period and the 6 months prior to the SACU opening was examined to determine any effect on critical care workload. RESULTS: The SACU admitted 131 patients during the audit period. There was no significant difference between predicted and observed mortality or morbidity. There was no effect on critical care length of stay after the SACU opened. Many patients who would have needed critical care beds before the SACU opened were admitted directly to the SACU after it opened. CONCLUSIONS: This audit demonstrates that the provision of a surgical acute care unit allows many patients who would normally need to be admitted to the critical care unit for postoperative care to be safely admitted to level 1 care beds.

Interleukin 6 production during abdominal aortic aneurysm repair arises from the gastrointestinal tract and not the legs.

BACKGROUND: Abdominal aortic aneurysm (AAA) repair is associated with a systemic inflammatory response. This inflammatory response probably arises as a result of an ischaemia-reperfusion injury to the legs and gastrointestinal tract. In this study the relative contributions of these areas to the inflammatory response were assessed during elective AAA repair. METHODS: Blood was sampled from the femoral vein, portal vein and radial artery of 14 patients undergoing elective AAA repair at five time points during the procedure. Plasma was snap-frozen for subsequent batch analysis of interleukin (IL) 6. RESULTS: The plasma IL-6 concentration rose steadily throughout the procedure at all three locations. The increase in plasma IL-6 was significantly greater in the portal vein than in the radial artery during ischaemia (P = 0.020). The plasma IL-6 concentration was also significantly higher in the portal vein than in the femoral vein (P < 0.001) and radial artery (P < 0.001) during reperfusion. There were no significant differences between radial artery and femoral vein IL-6 levels at any time point. CONCLUSION: Ischaemia and reperfusion during AAA repair were associated with a marked increase in IL-6 concentration in the portal vein, suggesting that IL-6 was produced by the gastrointestinal tract.

Ischaemia-reperfusion injury and regional inflammatory responses in abdominal aortic aneurysm repair.

OBJECTIVES: The inflammatory response to abdominal aortic aneurysm repair is likely to result in response to an ischaemia-reperfusion injury (IRI) to the lower-limbs and gastrointestinal tract. This paper reviews the pathogenesis of the inflammatory response to abdominal aortic aneurysm repair, with specific reference to the levels of evidence in the current literature regarding the potential origin of the inflammatory response. DESIGN: Review article. METHODS: The current literature (1966 to August 2003) was reviewed specifically for all articles employing techniques of regional blood sampling from the venous drainage of the lower limbs or gastrointestinal tract during abdominal aortic aneurysm repair. RESULTS: Ten relevant studies were identified. These demonstrated that regional blood sampling techniques could be easily performed, and provided useful information regarding the potential sites of origin of the inflammatory response. CONCLUSIONS: Regional blood sampling techniques provide useful information regarding the potential sites of origin of the inflammatory response. Current evidence suggests that both the lower limbs and gastrointestinal tract are clearly important in their roles, however more work is now required to compare directly the roles and contributions of the lower limbs and gastrointestinal tract to the inflammatory response during abdominal aortic aneurysm repair.

Evaluation of the role of a specialist tracheostomy service. From critical care to outreach and beyond.

The impact that a new specialist tracheostomy service, designed specifically for the care of patients with tracheostomies, was assessed in terms of type of tracheostomy tube used, time to first tube change, time to decannulation, and incidence of tracheostomy related complications in a teaching hospital with no on-site ear, nose, and throat facility. A total of 170 patients were studied. After service implementation, fewer patients (17.6%, n = 21) were discharged from the intensive treatment unit to the wards with tracheostomy tubes compared with the first group (39%, n = 20) (p = 0.006), and the number of tracheostomy related complications on the wards were significantly reduced (p = 0.031).

Feasibility of preoperative computer tomography in patients with ruptured abdominal aortic aneurysm: a time-to-death study in patients without operation.

INTRODUCTION: Despite advances in surgery, anaesthesia, and critical care, mortality from ruptured abdominal aortic aneurysms (AAAs) has not decreased over the last 20 years. Endovascular aneurysm repair (EVAR) of ruptured AAAs is an alternative to open repair, which may improve outcome. However, a computed tomography (CT) scan is usually required to assess the anatomic suitability of the aneurysm for EVAR. This may result in delay in transferring patients to the operating room. We evaluated all patients admitted to hospital with a ruptured AAA who died without undergoing surgery, to determine time to death after AAA rupture and thus the potential time available for obtaining a CT scan. METHODS: A retrospective case note review was conducted of 56 patients admitted to a single center with ruptured AAAs who did not undergo surgery because of advanced age or associated comorbidity over 8 years from 1995 to 2003. Statistical analysis was performed with the Fisher exact test. RESULTS: The 56 patients (33 men, 59%; 23 women, 41%) had a median age of 85 years (range, 71-98 years). Reasons for no operation being performed were shock (9%), cardiac arrest (11%), quality of life (29%), malignancy (7%), cardiac disease (15%), respiratory disease (16%) and age (14%). Median systolic blood pressure at admission was 110 mm Hg, heart rate was 88 beats per minute, and hemoglobin concentration was 10.5 g/dL. Patients were not aggressively resuscitated once a decision was made to not perform surgery. Death within 2 hours of hospital admission occurred in 7 (12.5%) patients, and 49 (87.5%) patients died more than 2 hours after admission. Median interval between onset of symptoms and admission to hospital was 2 hours 30 minutes (range, 44 minutes-36 hours), and the median interval between admission and death was 10 hours 45 minutes (range, 1 hour 1 minute-143 hours 55 minutes). The median total time to death from onset of symptoms was 16 hours 38 minutes (range, 2 hours 6 minutes-146 hours 50 minutes). CONCLUSION: Most (87.5%) patients admitted to hospital with a ruptured AAA died after more than 2 hours. These data show that most patients with a ruptured AAA who reach the hospital alive are sufficiently stable to undergo CT and consideration of EVAR.