Laohathai Sirasit, Jaroensuk Jittima, Laohathai Sira, Laohavinij Wasin
Department of Surgery, Chonburi Hospital, Chonburi, Thailand.
Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
Trauma Surg Acute Care Open. 2021 Mar 4;6(1):e000570. doi: 10.1136/tsaco-2020-000570. eCollection 2021.
Even though an acute care surgery (ACS) model has been implemented worldwide, there are still relatively few studies on its efficacy in developing countries, which often have limited capacity and resources. To evaluate ACS efficacy in a developin country, we compared mortality rates and intervention timeliness at a tertiary care center in Thailand among patients with an upper gastrointestinal hemorrhage (UGIH).
This retrospective study compared two 24-month periods between pre-ACS and post-ACS implementations from July 1, 2014, to June 30, 2018. Medical records from consecutive patients with UGIH in the surgical department of Chonburi Hospital, Thailand, were reviewed. The primary outcome was UGIH mortality rate differences between pre-ACS and post-ACS implementations. Differences in complications rate, length of hospital stay (LOS), time to esophagogastroduodenoscopy (EGD) and proportion of patients undergoing esophagogastroduodenoscopy (%EGD) in the same admission were also analyzed using unpaired t-test and Fisher's exact test. Baseline characteristic differences between the pre-ACS and post-ACS periods were controlled for in multiple linear and logistic regression models.
A total of 421 patients were included (162 pre-ACS and 259 post-ACS). Results showed a mortality rate of 24% in post-ACS compared with 41% in pre-ACS period (p<0.001). Overall complications (38% vs 27%), LOS (6.4 days vs 5.6 days) and time to EGD (44 hours vs 25 hours) were also significantly reduced, whereas %EGD increased (70% vs 89%). After adjusting for covariates, patients in the post-ACS period had lower risk of death (OR 0.54, p=0.040), lower risk of developing respiratory complications (OR 0.52, p=0.036), higher chance of receiving EGD in the same admission (OR 2.94, p<0.001) and shortened time to EGD for 19 hours (p<0.001).
Our results provide evidence that ACS can be implemented to improve patient outcomes at medical centers in developing countries with limited resources.
Therapeutic/care management, level IV.
尽管急性护理手术（ACS）模式已在全球范围内实施，但在资源和能力往往有限的发展中国家，关于其疗效的研究相对较少。为了评估ACS在一个发展中国家的疗效，我们比较了泰国一家三级护理中心上消化道出血（UGIH）患者的死亡率和干预及时性。
这项回顾性研究比较了2014年7月1日至2018年6月30日ACS实施前和实施后两个24个月的时间段。回顾了泰国春武里医院外科连续的UGIH患者的病历。主要结局是ACS实施前和实施后UGIH死亡率的差异。还使用不成对t检验和Fisher精确检验分析了并发症发生率、住院时间（LOS）、食管胃十二指肠镜检查（EGD）时间以及同一住院期间接受食管胃十二指肠镜检查的患者比例（%EGD）的差异。在多元线性和逻辑回归模型中控制了ACS实施前和实施后时期的基线特征差异。
共纳入421例患者（ACS实施前162例，实施后259例）。结果显示，ACS实施后的死亡率为24%，而实施前为41%（p<0.001）。总体并发症（38%对27%）、LOS（6.4天对5.6天）和EGD时间（44小时对25小时）也显著降低，而%EGD增加（70%对89%）。在调整协变量后，ACS实施后的患者死亡风险较低（OR 0.54，p=0.040），发生呼吸并发症的风险较低（OR 0.52，p=0.036），在同一住院期间接受EGD的机会较高（OR 2.94，p<0.001），EGD时间缩短19小时（p<0.001）。
我们的结果提供了证据，表明在资源有限的发展中国家的医疗中心可以实施ACS来改善患者结局。
治疗/护理管理，IV级。
