Delays by patients, emergency physicians, and surgeons in the management of acute appendicitis: retrospective study.

OBJECTIVES To compare the contributions of patients, emergency physicians, and surgeons in the delay of diagnosis and treatment of appendicitis, and the effects of delay on disease stage and complication rate. DESIGN Retrospective study. SETTING Accident and emergency department of a district public hospital, Hong Kong. PATIENTS All patients undergoing emergency appendectomy between August 1998 to September 1999. MAIN OUTCOME MEASURES Patient delay in presentation, emergency physician delay in hospital admission, and surgeon delay in performing the operation; operative findings; and postoperative complications. RESULTS Of 158 patients undergoing emergency operation, 14 had no pathological diagnosis and four had a diagnosis other than that of acute appendicitis. Of the 140 pathologically confirmed cases of appendicitis, the mean emergency patient delay was greater in advanced appendicitis than it was in simple appendicitis (42.0 hours versus 24.9 hours; P<0.005). The mean emergency physician delay in advanced appendicitis was also greater than it was in simple appendicitis (17.9 hours versus 5.8 hours; P<0.05). The difference in the mean surgeon delay in simple (10.9 hours) and advanced (16.3 hours) appendicitis, however, was not significant. The mean emergency physician delay showed a significant association with the postoperative complication rate (P=0.05). The delay was mainly because of a failure to diagnose the condition and admit the patient at the first visit to the accident and emergency department (22.1%). The diagnostic accuracy showed a significant association with the level of experience of the emergency physician involved (P<0.05). CONCLUSION There should be a higher index of suspicion, better surgical training, and better senior supervision at accident and emergency departments, to avoid preventable morbidity and mortality in acute appendicitis.