Implementation of support for appendicitis in ambulatory 24h/24 at Pitié-Salpêtrière hospital

The hospital of the Pitié-Salpêtrière hospital (AP-HP), under the leadership of Pr Mehdi Karoui (Department of digestive Surgery and Hepato-bilio-pancreatic) and Bruno Riou (Emergency Department) has implemented a support of acute appendicitis, non-complicated outpatient 24 hours on 24 hours. This support is based on a particular organization developed in connection with the services emergency, anesthesia-resuscitation and surgery of the Pitié-Salpêtrière hospital (AP-HP). It is the object of a publication in the journal, World Journal of Surgery.

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The new organization deployed based on different steps : 1) identification upon arrival at the emergency department of patients presenting for suspected acute appendicitis ; 2) balance sheet data (clinical, biological, morphological) made to the emergency room to make the diagnosis of acute appendicitis, non-complicated ; 3) validation of the criteria of ambulatory surgery by the er physician, the surgeon and the anesthesiologist (little or no co-morbidities, presence of an accompanying understanding of the protocol of outpatient surgery) ; 4) intervention carried out with a certain prioritization ; 5) output 4 to 6h after the intervention with the establishment of a monitoring protocol post-operatively once the exit criteria (pain, power) validated by the surgeon and the anaesthetist; 6) consultation with post-operative early surgery.

This organization, which meets the requirements of safety and blending of the course of patient care, is original because it extends the concept of outpatient surgery in the emergency room. It can be extended to other hospitals because it does not require a structure of ambulatory surgery dedicated. It allows you to optimize the beds of surgery downstream, while offering the patient comfort and security.

If per-operatively, the surgeon considers that it is a complicated appendicitis, or that exit criteria are not met, then the patient is hospitalized in hospital conventional.

Indeed, es interventions in ambulatory surgery require a selection of patients (patients without pathology major associated, with the presence of a companion at home, dwelling-place relatively close to the hospital), as well as information and education, therapeutic preoperative appropriate.

The hospitalization conventional of the patient may be preferred in several situations :

> if the criteria pre-operative of appendicitis, non-complicated are not met ;

> if the surgeon finds intraoperatively as a complication not identified pre-operatively ;

>post operative-immediate exit criteria “ambulatory” are not met (for example the absence of accompanying adult for the return home).

Today at the hospital of the Pitié-Salpêtrière hospital (AP-HP), a second patient with appendicitis benefits of outpatient surgery in an emergency.

The outpatient surgery at the AP-HP

The outpatient surgery is a surgery with a duration of hospitalization of less than 12h. Because it is beneficial for the health of the patients and less costly for the company, its development has become a national priority. It must be surgical techniques perfectly standardized, regulated with limited risks and clearly identified.

The AP-HP encourages its development, when this is possible, and has set an ambitious goal : by 2019, the AP‑HP has given a target of achieving 45 % of its interventions in ambulatory surgery.

To achieve this, priority axes have been defined. This is mainly to improve the care of patients in the units of outpatient surgery, and to accelerate the transfer of activities currently performed in hospital full on several days. It is also necessary to better inform patients and physicians of the city of the offer proposed by the hospital, to reinstate activities of the ambulatory today addressed to other institutions and, finally, to develop collaborations with partners in the city to organize suites of the hospital.

The rate of ambulatory surgery (AP‑HP) has increased from 33.9 % to 35.7% in 2016.

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