MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.
"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.
Patrice Wendling/IMNG Medical Media
Dr. Wendy L. Wahl
She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.
As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.
Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.
The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.
The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.
After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).
The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.
"About half of the patients could have had their process improved," she observed.