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Nonoperative management of acute appendicitis is becoming widespread, but recurrence and the potential for a complicated course are important concerns. An admission report-based institutional database was created to monitor appendicitis treatment outcomes. Complications and complexity of surgery were recorded based on manual chart review. A cohort of patients spanning one year was analyzed. Initial management was operative in 181 (82%) and nonoperative in 39 (18%) cases. There were no differences in demographics, BMI, or Alvarado score. One operative patient and 17 nonoperative patients required additional treatment for recurrence/nonresolution (0.6% vs 44%, P < 0.00001). Twenty-eight (15%) operative patients and 17 (44%) nonoperative patients had complications ( P = 0.0003). Thirty-six (19.9%) operations in the operative group and 8 (53.3%) in the nonoperative group were classified as complex ( P = 0.007). Hospital stay was longer in the nonoperative group (one vs two days, P = 0.005). Two incidental malignancies in the operative group and one in the nonoperative group were identified. These results are consistent with prior studies showing that recurrence/nonresolution is common after nonoperative management. For patients with recurrence/nonresolution, surgery may be more complex.

Background: Prolonged emergency department (ED) stays correlate with negative outcomes in critically ill nontrauma patients. This study sought to determine the effect of ED length of stay (LOS) on trauma patients., Materials and Methods: Two hundred forty-one trauma patients requiring direct intensive care unit (ICU) admission were identified. Patients requiring immediate operative intervention were excluded. Odds ratios (ORs) of outcomes for patients transferred to ICU in ≤90 min were compared with patients transferred in >90 min, adjusting for Injury Severity Score (ISS)., Results: One hundred two of 241 patients (42%) were transferred to the ICU in ≤90 min. Increased ED LOS was associated with decreased complications (OR 0.545, 95% confidence interval 0.312-0.952). Although the result was not statistically significant, patients with an ISS >15 were less likely to have long ED stays (OR 0.725, 95% CI 0.407-1.290). No significant difference was seen in mortality. No difference in duration of intubation was observed for patients intubated in the ED versus the ICU. For the subgroup with ISS ≤15, there was a significant decrease in ICU LOS for patients who remained in the ED >90 min (5.5 d versus 2.7 d, P = 0.02). No other differences in LOS were identified., Conclusions: In a mature trauma center with standardized activation protocols and focused resource allocation in the ED trauma bay, trauma activation and subsequent management appear to mitigate the negative effects of prolonged ED LOS seen in other critically ill populations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The American College of Surgeons (ACS) recommends trauma overtriage rate (OT) below 50 per cent to maximize efficiency while ensuring optimal care. This retrospective study was undertaken to evaluate OT rates in our Level I trauma center using the most recent criteria and guidelines. OT rates during a 12-month period were measured using six definitions based on combinations of Injury Severity Score (ISS), length of hospital stay (LOS, in days), procedures, and disposition after the emergency department. Reason for trauma activation was 55 per cent criteria, 16 per cent guidelines, 11 per cent paramedic judgment, five per cent no reason, and 13 per cent no documentation. OT rates ranged from 22.6 per cent (ISS less than 9, LOS 1 day or less, no consults) to 48.2 per cent (ISS less than 9, LOS 3 days or less, with procedures/consults) and were in compliance with ACS recommendations. Physiologic assessment criteria and anatomic injury had the lowest OT rates and contained all mortalities. Passenger space intrusion (PSI), pedestrian versus automobile (criterion and guideline), and extrication (guideline) all had consistently high rates of OT. We conclude that PSI should be reduced to a guideline, the pedestrian versus automobile criterion and guideline should be combined, and extrication could be removed from the triage scheme.