In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.
After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).
The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).
Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.
Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.
"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.
Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.
Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.
Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.
Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.
"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."
When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.
Dr. Wahl and her coauthors reported no conflicts of interest.