Comparative study between patients with acute appendicitis treated in primary care units and in emergency hospitals

OBJECTIVE
To retrospectively analyze the relationship of time of care, combined with possible post-appendectomy complications, with the promptness of transfer of patients seen in Emergency Care Units (UPA) to the emergency hospital.


METHODS
We analyzed patients with preoperative diagnosis of acute appendicitis undergoing appendectomy from January to July 2012. Patients were divided into two groups according to the site of the first care. Group A included patients who received initial care directly in the emergency department of the Lourenço Jorge County Hospital (HMLJ) and group B consisted of patients seen in the UPA and forwarded to HMLJ to undergo surgical treatment.


RESULTS
the average time between initial treatment and surgery in group A was 29 hours (SD = 21.95) and 54 hours in group B (SD = 54.5). Considering the onset of symptoms, the patients in group A were operated on average 67 hours after (SD = 42.55), while group B, 90 hours (SD = 59.58). After the operation, patients in group A were hospitalized, on average, for 94 hours (SD = 73.53) and group B, 129 hours (SD = 193.42).


CONCLUSION
there was no significant difference in the time elapsed between the onset of symptoms, initial treatment and early surgical treatment, or time elapsed between surgery and discharge.


INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION
A cute appendicitis is the most common cause of emergency care in hospitals and it is the most frequent abdominal inflammatory disease of surgical treatment in young people 1,2 .It predominates in males at a ratio of 1.4: 1 and the lifelong risk of developing it is 8.6% for men and 6.7% for women 3 .
Abdominal pain is the most common and early symptom.It starts in the mesogastric region and migrates to the right iliac fossa 4 , having a strong association with the diagnosis of acute appendicitis 5 .
In recent years, ultrasound (US) and computed tomography (CT) have been widely used in patients with a clinical features of acute appendicitis to clarify the diagnosis 6 .The ultrasound has a sensitivity of 85% 7 .However, CT has higher accuracy 8 .The use of this exam in patients with suspected appendicitis or in those with diagnostic uncertainty greatly decreased the rates of negative laparotomy 9 .
Disease severity is directly connected to evolution time.Perforation is the most common complication and is associated with delayed diagnosis.Thirty-six hours after the onset of symptoms the risk of perforation is 16-36%, and this risk increases approximately 5% every 12 hours 10 .
Morbidity and mortality are also related to the time evolution and hence to perforation.The mortality rate in nonperforated appendicitis is 0.08% and 0.51% in the cases where there is perforation 11 .Similarly, the complications are more frequent in patients operated later 1 .Thus, efforts must be focused on early diagnosis and treatment, aiming at lower morbidity and mortality.
In 2003, the Brazilian Ministry of Health established a National Policy for Emergency Department in order to structure and organize the network of emergency care in the country 12 .The Emergency Care Units (UPAs) are structures of intermediate complexity that are part this program.After risk classification, patients with abdominal pain and clinical suspicion of acute appendicitis seen in these units may, according to a regulation system, be referred to an emergency hospital for surgical treatment.
Since the morbidity and mortality of acute appendicitis are directly linked to the progression of the disease, a delay in treatment due to the need for a transfer between healthcare facilities could increase complications and mortality in this group of patients.Therefore, we decided to retrospectively analyze relationship of time of care, combined with possible post-appendectomy complications, Bon Bon Bon Bon Bon Comparative study between patients with acute appendicitis treated in primary care units and in emergency hospitals with the promptness of transfer of patients seen in the UPAs to the emergency hospital.

METHODS METHODS METHODS METHODS
We retrospectively analyzed the patients who underwent appendectomy at the LorenzoCounty Hospital (HMLJ) in Rio de Janeiro between the months of January and July of 2012.Patients were divided into two groups according to the place where they received the first care.Group A consisted of patients who spontaneously sought the emergency room of HMLJ, where they were operated.Group B consisted of patients initially treated at UPAs of Rio de Janeiro, and later taken to the HMLJ for surgical treatment after effective evaluation of signs and symptoms and diagnostic confirmation.Elapsed times evaluated were: between onset of symptoms and start of appendectomy (t1); between the initial treatment and start of appendectomy (t2); and between the operation and hospital discharge (t3).The time intervals were measured in hours.We analyzed and compared the complications in each group.The Student t test was used for evaluation of time intervals and we considered p values <0.05 as statistically significant.

RESULTS RESULTS
We analyzed medical records of 24 patients in group A and 34 in group B. The males prevailed in both groups and there was no difference in mean age between groups (Table 1).
All patients had abdominal pain.There was no significant difference between the number of patients who had localized or diffuse pain between the groups.However, we found a high percentage of patients with diffuse abdominal pain.Sixty-eight percent of patients in group B had vomiting (Figure 1).
Intraoperative evaluation demonstrated that 63% of patients in group A and 66% of group B had suppurating appendicitis with perforation or necrosis (Table 2).
There was no significant difference in the time interval between symptom onset and appendectomy (t1,) between the initial treatment and appendectomy (t2) and the time of hospitalization after surgery (t3), although the average time in hours was higher in group B (Table 3).
The percentage of complications was similar, regardless of the location of the initial treatment (Table 4).

DISCUSSION
DISCUSSION DISCUSSION DISCUSSION DISCUSSION The Emergency Care Units, part of the National Emergency Policy, allowed more health facilities to be available to the population and closer to their homes.On the other hand, the inclusion of a further step in the treatment of those whose prognoses are connected to early treatment could worsen results and increase morbidity and mortality.
It its known that even in developed countries like the United States, patients undergoing appendectomy for acute appendicitis at government hospitals more often present with perforation and require longer hospital stay compared with those treated in private hospitals 13 .According to data from the US National Hospital Ambulatory Medical Care Survey, between 1997 and 2006 the waiting time for diagnosis was higher in the lower income population 14 .The same happens in our country.Coelho et al. published longer hospital stays, greater number of postoperative complications and delayed return to normal activities in      patients operated in a public hospital when compared with those operated on a private unit 15 .
In this study, it appears that, regardless of the location of the first visit, the patients clearly showed a long time between onset of symptoms and surgical treatment, as well as a prolonged mean hospital stay, even compared with other Brazilian public hospitals 16 .
Also noteworthy is the high number of appendicitis with perforation and necrosis, compatible with advanced disease and therefore with a worse prognosis.
One can also observe a trend of increase of the time elapsed between onset of symptoms and surgery (t1), of the time between the initial treatment and surgery (t2), as well as increased length of postoperative hospital stay (t3 ) in patients initially treated at UPAs when compared with those treated directly at the Hospital.However, as for the quantum analyzed, this difference was not significant.An amplification of the number of patients could confirm this finding.

Figure 1 Figure Figure 1 Figure 1 Figure 1 -
Figure 1 Figure Figure 1 Figure 1 Figure 1 -Comparison of percentage of signs and symptoms observed in patients seen in the UPA and in HMLJ.

Table 1 Table 1 -
Patients undergoing appendectomy, according to gender and average age.

Table 3 Table 3 Table 3 Table 3 Table 3 -
Average time, in hours, between the first care until hospital discharge, according to the location of the first care.

Table 4 -Table 4 -Table 4 -Table 4 -Table 4 -
Percentage of complications observed after appendectomy by according to the location of the first care.