Delays in presentation, severity of illness, and adverse surgical outcomes among patients transferred from Nunavik for acute care surgery.

Abstract

Background: Providing acute care surgery (ACS) to Nunavik, Quebec, is highly challenging because of health care infrastructure and access issues, with geographic distances and delays in transport translating to suboptimal care, particularly for acute surgical conditions requiring timely intervention. The main objective of this study was to identify clinical predictors of poor surgical outcomes in patients transferred from Nunavik to a tertiary care centre for operative ACS conditions.

Methods: We conducted a retrospective cohort study at the Montreal General Hospital (MGH), the main tertiary care centre providing ACS care to Nunavik. We included all adult patients who were transferred from Nunavik to the MGH and underwent a surgical intervention for an ACS condition between 2015 and 2020. The outcome of interest was the occurrence of a postoperative complication, as defined by the Clavien-Dindo classification.

Results: In total, 177 patients were transferred from Nunavik to the MGH and underwent a surgical intervention for an ACS pathology during the study period. The mean age was 40.0 (standard deviation 16.7) years, and half the patients (n = 90, 50.8%) were female. The most common ACS pathology was acute cholecystitis (n = 65, 36.7%), followed by acute appendicitis (n = 51, 28.8%) and biliary pancreatitis (n = 13, 7.3%). Forty-six (26.0%) patients had a postoperative complication of Clavien-Dindo grade 1 or higher. On univariate analysis comparing patients who experienced complications to those who did not, we observed significant differences in age, sex, Emergency Surgical Score (ESS), delays in operative intervention, proportion of open surgical interventions, proportion of intraoperative perforations, admissions to the intensive care unit, and hospital length of stay. On multivariable logistic regression, male sex (odds ratio [OR] 2.75, 95% confidence interval [CI] 1.22 to 6.17), higher ESS (OR 1.28, 95% CI 1.03 to 1.59), higher American Society of Anesthesiologists (ASA) score (OR 2.28, 95% CI 1.23 to 4.24), and longer delays in presentation (OR 1.07, 95% CI 1.01 to 1.14) were predictive of postoperative complications.

Conclusion: Delays in presentation and severity of illness on arrival are associated with worse postoperative outcomes for patients with ACS conditions transferred from Nunavik to an urban tertiary care centre. Identifying these predictors of poor postoperative course will help shape future quality improvement initiatives, which should focus on point-of-care resuscitation, improved transport logistics and resources, and ultimately improved access to on-site surgical care.