Hendra Louise, Hendra Tim, Parker Stephen J
General Surgery Department, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, England, UK.
Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, BH15 2JB, England, UK.
World J Surg. 2019 Mar;43(3):798-805. doi: 10.1007/s00268-018-4849-6.
More than 30,000 emergency laparotomies take place annually in England and Wales (Symons et al. in Br J Surg 100(10):1318-1325, 2013; Shapter et al. in Anaesthesia 67(5):474-478, 2012). They are associated with high morbidity and an average inpatient 30-day mortality rate of 11%. Inextricably linked to outcomes is the decision-making process of whether or not to operate (NELA Project Team First patient report of the National Emergency Laparotomy Audit. RCoA, London, 2015; Crebbin et al. in Aust N Z J Surg 83(6):422-428, 2013). A mixed-methods study was undertaken to investigate decision-making in the emergency laparotomy and influencing factors.
Semi-structured interviews were undertaken amongst general surgeons, exploring the decision-making process. Results helped guide design of an online survey, consisting of vignettes and subsequent questions. Respondents were asked to decide whether or not they would perform a laparotomy for each vignette and the results compared to grade, risk attitudes and reflective practice. Responses were analysed for effect of previous positive and negative experiences and for consistency.
Interviews revealed multiple important factors when considering whether or not to perform an emergency laparotomy, broadly categorised into patient-related, surgeon-related and external factors. A total of 116 general surgeons completed the survey: 12 SHOs, 79 registrars and 25 consultants. Non-consultants were 10.4% (95% CI ±9.7%) more likely to perform an emergency laparotomy than consultants (p = 0.036) on multivariate analysis. No association was observed between operative practices and risk attitudes (p = 0.22), reflective practice (p = 0.7) or previous positive or negative experiences in univariate (p = 0.67) or multivariate analysis. Surgeons were not proven to be either consistent nor inconsistent in their decision-making.
The decision to operate or not in an emergency laparotomy directly effects patient outcome. This study demonstrates a difference in decision-making and risk attitudes between consultants and their juniors. To address this, formal teaching of models of decision-making, influencing factors and vignette-based consultant-led discussions should be introduced into surgical training.
在英格兰和威尔士，每年进行超过30000例急诊剖腹手术（西蒙斯等人，《英国外科学杂志》，2013年，第100卷第10期，第1318 - 1325页；沙普特等人，《麻醉学》，2012年，第67卷第5期，第474 - 478页）。这些手术伴随着高发病率，住院30天的平均死亡率为11%。是否进行手术的决策过程与手术结果有着千丝万缕的联系（国家急诊剖腹手术审计项目团队，《国家急诊剖腹手术审计的第一份患者报告》。皇家麻醉师学院，伦敦，2015年；克雷宾等人，《澳大利亚和新西兰外科学杂志》，2013年，第83卷第6期，第422 - 428页）。本研究采用混合方法调查急诊剖腹手术中的决策制定及影响因素。
对普通外科医生进行半结构化访谈，探讨决策过程。研究结果有助于指导在线调查问卷的设计，该问卷包括病例描述及后续问题。要求受访者针对每个病例描述决定是否进行剖腹手术，并将结果与医生级别、风险态度和反思性实践进行比较。分析受访者以往积极和消极经历的影响以及回答的一致性。
访谈揭示了在考虑是否进行急诊剖腹手术时的多个重要因素，大致可分为与患者相关、与外科医生相关和外部因素。共有116名普通外科医生完成了调查：12名住院医师、79名专科住院医生和25名顾问医生。多因素分析显示，非顾问医生进行急诊剖腹手术的可能性比顾问医生高10.4%（95%置信区间±9.7%）（p = 0.036）。在单因素（p = 0.67）或多因素分析中，未观察到手术操作与风险态度（p = 0.22）、反思性实践（p = 0.7）或以往积极或消极经历之间存在关联。未证实外科医生在决策过程中具有一致性或不一致性。
急诊剖腹手术中是否进行手术的决策直接影响患者的治疗结果。本研究表明顾问医生与其下级医生在决策和风险态度上存在差异。为解决这一问题，应将决策模型、影响因素的正式教学以及基于病例描述的由顾问医生主导的讨论引入外科培训。
