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| Journal of the New Zealand Medical Association,
22-May-2009, Vol 122 No 1295
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Management of adult superficial acute abscesses in a
tertiary hospital: time for incisive action
Jannah Baker, John Windsor
Demand on acute operating theatres in busy hospitals means
that patients with superficial acute abscesses often have to wait for many hours
or days before relatively simple procedures can be performed. These patients
either have procedures done late at night, after more urgent cases have been
done, have to stay until the next day, with repeated periods of delay and
starvation awaiting the availability of an acute theatre.
Demand on emergency departments means that these patients
are admitted to a surgical ward pending treatment. Hospital bed occupancy is
commonly more than 90% and patients admitted with acute minor problems often
prevent elective admission of patients with major problems. Although most large
hospitals have day case surgery units, there has been a tendency, at least in
Auckland, for these to be on a different hospital campus from the acute
services.
The Royal College of Surgeons of England, in its guidelines
for day case surgery (1992), states that “day surgery is now considered
the best option for 50% of all patients undergoing elective surgical
procedures”.1 Although this has not been
extended to acute procedures, a number of studies have shown that certain types
of abscess can be safely and successfully treated as day case procedures. These
include superficial abscesses2, pilonidal
abscesses3 and Bartholin gland
abscesses4. Follow-up has shown good results
for patients after day case surgery. Patients in these studies were generally
young and otherwise healthy, and required a relatively short operating time, so
a day case service for such patients appears appropriate and feasible.
There are a number of potential benefits of day case surgery
for patients with a superficial acute abscess. From a healthcare perspective
these benefits include decreased hospital costs, enabling dollars saved to be
allocated elsewhere, reduced risk of nosocomial infection and of development of
antibiotic-resistant organisms, as well as decreased risks of further infection
and complications. Importantly, a day case service would relieve pressure on
hospital beds.
From a patients perspective, a day case service would also
decrease the amount of time patients spend away from work thereby maintaining
their productivity in the community, and decrease recovery time and
inconvenience to patients and their families. Previous research in this area has
suggested that patients with significant but controlled systemic disease (ASA
score 3—severe but not life-threatening)5
may also be suitable for treatment as day
cases6.
The aim of this study was to review trends in the management
of adult patients with acute superficial abscesses over a 15-year period at a
major tertiary hospital, and to determine if significant benefits would be
obtained by managing them as day cases.
MethodsStudy design—Patients were
identified using the Otago Surgical Audit (Otago Clinical Audit and Outcomes
Unit, Dunedin, New Zealand), an electronic surgical audit system that has been
used in a wide spectrum of surgical practices in Australasia, and has been
described in detail elsewhere.7–9 Data on
all adult general surgical patients at Auckland City Hospital between 1992 and
2007 with a primary or secondary diagnosis coding of “abscess” were
retrieved and entered into an Excel spreadsheet.
Data were screened for duplicate case records and
non-abscess procedures. Of the remaining data (classified as “all
cases”), a subset of patients who may potentially have been suitable for
day case surgery was identified. Inclusion criteria were superficial abscesses;
ASA 1 or 2; procedure length ≤60 minutes; no concomitant major procedure
done in addition to abscess procedure; preoperative stay ≤5 days;
postoperative stay ≤2 days.
Exclusion criteria included patient age ≤15
years); procedures that found no drainable collection, e.g. debridement alone or
examination under anaesthesia alone. Patients not fulfilling all of the
selection criteria for “potential day cases” were classified as
“excluded cases”.
In addition, patients were identified in the study data
who had actually been admitted, operated on and discharged on the same date, and
were classified as “actual day cases”. This subset overlapped to
some extent with both the “potential day cases” and “excluded
cases” subsets.
Data on these subsets were analysed with regard to
median length of stay; mean duration of procedure; comparison with patients of
ASA score 3 fulfilling all other criteria for a potential day case procedure;
effect of surgical specialty on preoperative length of stay; trends over time in
numbers of cases; trends in numbers of admissions and procedures performed on
different days of the week; and types of procedures performed.
Statistical analysis—Chi-squared
analysis was used to investigate for a significant difference in numbers of
breast and perianal/rectal abscess cases performed by the three general surgical
specialty teams.
Results2475 patients were admitted with the diagnosis of abscess
during the study period. Of these, 59% (n=1455) were classified as potential day
case patients. Of the original 2475 patients, 6% (n=146) were actually treated
as day cases. The annual incidence of abscess cases treated by the Department of
General Surgery is shown in Figure 1 for each subgroup.
Figure 1. Annual incidence of number of
admissions to the Department of General Surgery with a diagnosis of abscess from
1992 to mid-2007
 The median age of patients classified as potential day cases
was 33 years (range 15-88) and was not significantly different from that of
patients treated as day cases (39 years, 15–83) or from that of those who
were excluded as not being potentially suitable for day case surgery (40 years,
0-91). Overall there was a non-significant trend towards more males than females
(1.1:1) and this was the case for each of the three categories.
Figure 2 shows the distribution of the ASA categories for
the three patient groups. The potential day cases, by definition, were ASA 1
(71%) and 2 (29%).
Figure 2. Distribution of ASA categories in
patients classified as potential day cases, actual day cases and excluded
cases
 The number and proportions of abscesses treated at each
anatomical site is shown in Table 1. The mean procedure duration in the
potential day case group was 16 ± 9 minutes (mean ± SD) which was not
different from that for the actual day case group (18 ± 10 minutes), but
both were significantly less than for the excluded cases (35 ± 46 minutes,
Mann-Whitney U, two-tailed, p <0.0001).
Admission of potential day case patients resulted in a
median hospital stay of 2 days (range 0–7, Figure 3). The median
preoperative stay was 0 days (0–5), or less than 1 day, and the median
postoperative stay was 1 day (0–2). A total of 1357 (90%) patients had a
total hospital stay of more than 24 hours in the potential day case group. This
accounted for 2338 bed days over the 15-year study period, or an average of 359
bed days per annum.
The influence of development of specialist teams within the
Department of General Surgery on the management of abscesses at different sites
was examined. Table 2 shows that there was a significant trend (Chi-squared
45.5, p<0.001) towards breast abscess patients being managed by the Breast
and Endocrine Team and perianal abscesses being managed by the Colorectal Team.
Management by a specialist team had no noticeable effect on the length of
preoperative hospital stay.
Table 1. Anatomical site, number of patients,
type of surgical procedure, and duration of treatment for different types of
abscess
I & D = incision and drainage, E & D = excision
and drainage, EUA = examination under anaesthesia; *I includes biopsy,
curettage, debridement, washout ; ** includes insertion of drain/Malecot,
insertion of Seton, proctoscopy/sigmoidoscopy, ultrasonography, biopsy,
curettage, debridement, washout, banding of haemorrhoids; *** includes fistula
operation.
Table 2. Management of breast and perianal
abscesses by three specialist teams within the Department of General Surgery (3
× 2 Chi-squared 45.5, p<0.001)
Influence of day of the week on numbers of admissions and
procedures was also examined. Overall, there was a decrease in the numbers of
admissions and procedures from Monday to Sunday. Figure 4 demonstrates that
there was not a consistent match between the number of admissions and procedures
performed on a day to day basis. On Monday and Friday, the number of admissions
exceeded the number of procedures. The number of procedures exceeded admissions
on Wednesday, Thursday, and Saturday.
Figure 3. Frequency distribution of
preoperative, postoperative, and total hospital stay for potential day case
patients
 Figure 4. Number of admissions and number of
procedures for each day of the week (pooled study data)
 DiscussionThese findings indicate that of all the patients with
superficial acute abscesses admitted under general surgery, 59% could have been
managed as day cases without requiring hospital admission. This relatively large
group of patients, on average, spent 2 days in hospital awaiting a surgical
procedure that took a mean duration of 16 minutes. The suitability of these
patients for day case procedures is supported by the similarity of their
demographic characteristics and procedure durations to those of actual day cases
over the study period.
Finance Department records from Auckland City Hospital
indicate that for the most recent 3-year period each superficial acute abscess
admission for less than 7 days incurred an average cost of $4440. The average
cost incurred by a patient with superficial abscess cases that was performed as
a day case was $1389. This indicates a potential saving of $3051 per patient if
a day case service was provided for suitable patients.
In 2006 there were 202 admissions of potential day case
patients with superficial abscess. It is therefore estimated that a potential
saving of $616,302 could have been made during 2006. Significant savings can
also be estimated on the basis of hospital bed occupancy. For example, in 2006,
approximately 404 days of hospital stay (202 potential day cases × average
2 days’ stay) could have been saved if an appropriate day case service
were available. In view of the anticipated increase in numbers of superficial
abscess patients in the future, provision of a day case service could translate
into even greater healthcare cost savings in terms of hospital stay.
Our results show an increasing number of total and potential
day case abscess patients being admitted to hospital under general surgery from
1992 to 2006. There are several possible explanations for the observed rise. It
might be due to increasing compliance with registration of abscess cases in the
Otago Surgical Audit database over time.
It was noted that very few potential day cases were recorded
from 1992 to 1996, which may reflect registration of only non-superficial
abscess types in this time period. The increase might also result from fewer
abscesses being managed in the community by general practitioners and by staff
in the Emergency Department. At least part of the increase is likely to arise
from a real increase in the incidence of abscesses in the general population.
Irrespective of the explanation, this study suggests that
there will be an increasing number of abscess case admissions in the future,
potentially exceeding available healthcare resources. This alone would be a
compelling reason for provision of a day case service for the management of
patients with superficial acute abscess.
It is not difficult to envisage what would be required to
provide a day case service for the management of superficial acute abscesses.
The initial treatment of these could be done “at the front door” in
an Emergency Department treatment room, in a procedure room associated with an
acute admissions ward, or in a theatre associated with an on-site day case
surgical facility. The introduction of such a service is not complicated, but
would require a culture change and the availability of a surgical registrar. If
a general anaesthetic were required, then this might still be possible in a day
case facility. Patients could be discharged for review the following day, at the
time of the post-acute ward round.
A previous study showed no difference in complication rates
between patients with ASA score 3 and those with ASA 1 and 2 undergoing day case
surgery6. In Natof’s 10-year prospective
study of 13,433 patients at a freestanding ambulatory centre in the US, 403
patients were classified according to ASA score. These included patients with
hypertension, history of coronary occlusion, rheumatic valvular heart disease,
asthma, chronic pulmonary disease and diabetes mellitus. There were three
complications in the ASA 3 patients, and there was no statistical difference in
complication rate between these patients and ASA 1 and 2 patients.
No significant differences were observed in mean procedure
duration or median preoperative and postoperative hospital stay between patients
with ASA score of 3 (severe but not life-threatening systemic disease) and
patients with ASA 1 and 2 who were deemed suitable for day case procedures.
Unfortunately no data on complication rates in these groups were available for
comparison. The lack of a significant difference in duration of postoperative
hospital stay between the groups6,10 supports
the theory that some patients with uncomplicated controlled systemic disease
could be candidates for day case surgery. Indeed, a number of ASA 3 patients
(n=12) had actually undergone day case procedures over the study period.
If patients with uncomplicated controlled systemic disease
were considered potentially appropriate candidates for day case surgery, it is
expected that they would be assessed on a case by case basis with regard to age,
comorbidities, anaesthetic risk, expected duration and complexity of their
procedure and estimated probability of postoperative
complications11. It would not be necessary to
consider ASA 3 patients for day case management to achieve significant savings,
and this might be considered as a second stage in the introduction of such a
service.
The three specialised general surgical teams at Auckland
City Hospital rotate admitting days on an equal basis, and would be expected to
admit similar numbers of patients with each type of abscess. The admitting team
might hand over particular types of abscess to a specialist team to do the
procedure. It is standard policy for such handovers to be made the morning
following admission, although in practice this may sometimes be done on the same
day. The effect of handover to a specialist team was apparent in this study.
Significantly more perianal and rectal abscess procedures
were performed by the colorectal team, and significantly more breast abscesses
by the head and neck/breast/endocrine team. It was expected that the handover
process would result in a longer preoperative stay for these types of abscess
when the surgical procedure was performed by the corresponding specialist team.
However there was no difference in preoperative stay between patients with
perianal/rectal abscesses and those with breast abscesses under the specialist
teams.
Although there were more potential day case admissions on
Mondays which generally tapered over the remainder of the week, a mid-week spike
was seen for numbers of procedures performed. Numbers of admissions and
procedures were almost equal on Sundays. This suggests that patients admitted on
Mondays are more likely not to have a procedure until the following day or two
days later. A trend was seen of more admissions on weekdays for the potential
day case group. This is surprising, because it was expected that patients would
be more likely to present to hospital in the weekends when the majority would
not be working and most general practices are closed, or at least that similar
numbers of patients would present on weekends and weekdays.
Possible explanations for this trend may be that either more
abscess procedures are performed by ED staff or there is a true increased rate
of patient admission on weekdays. Unfortunately, no complete dataset was
available for analysis from the Auckland City Hospital Emergency Department on
their abscess admissions and procedures.
A limitation of this study is that it was a retrospective
audit of a surgical database and is therefore prone to input bias. It is
unlikely that all abscess procedures undertaken over the study period were
included. Also, there was increased compliance with the registration of cases
over the study period. Another limitation is that there are no reliable data on
complication rates.
Further research might include a prospective study of ASA 3
patients compared with ASA 1 and 2 patients regarding management and outcome of
those treated as day cases. It would also be useful to do a community-wide study
to look at the management of superficial acute abscesses in all settings,
including self-care, family practices, private accident and emergency
facilities, public emergency departments, existing day case facilities, as well
as inpatient care.
ConclusionThis study is important because it highlights a common and
increasing problem that is being managed inefficiently. The day case treatment
of appropriate patients with superficial acute abscesses has the potential to
save expenditure, release hospital beds and improve the overall care of
patients.
Competing interests: None known.
Author information: Jannah Baker, House
Officer, Department of General Surgery, Auckland City Hospital; John A Windsor,
Professor of Surgery, School of Medicine, Faculty of Medical and Health
Sciences, University of Auckland
Correspondence: Professor John Windsor,
Room 12-087, Level 12, ACH Support Building, Private Bag 92019, Auckland, New
Zealand. Fax: +64 (0)9 3779656; email: j.windsor@auckland.ac.nz
References:
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