Assessment of abdominal pain in older people: a quality improvement project in the emergency department

Nur Nurmahomed; Robert Bickerton; Claire Bronze

doi:10.7861/fhj.9-2-s94

Introduction

The cause of acute abdominal pain can hold great uncertainty. In older people this is further complicated by co-existent disease, delays in presentation and physical/social barriers. With increased risk of serious and rapidly progressive pathology associated with a 6–8-fold increase in mortality in comparison to younger patients.¹ At present, there is no defined pathway in the assessment of older patients with acute abdominal pain. This QIP aims to look at the assessment of older patients presenting with abdominal pain to St Mary's Hospital London emergency department.

Methods

Older patients over the age of 70 years presenting with abdominal pain were retrospectively selected. Data was collected on baseline demographics, comorbidities, investigations/imaging, senior review assessment and referral to specialty. After the initial audit, we presented a slide detailing triage investigations daily at morning handover, and held a teaching session for doctors assessing these patients. We then re-audited in two subsequent cycles to assess the efficacy of these interventions.

Results and discussion

Between 1–17 October 2021, 45 patients over the age of 70 presented with abdominal pain. Overall, the majority of patients were men (62%), the median age was 80.3 years and 20% of patients had four or more comorbidities. Hypertension (15%) and type II diabetes mellitus (15%) being the most common. Only 5–6% of patients had previous surgery or existing abdominal pathology. 92% of patients had a C-reactive protein (CRP) test, 68% had an amylase and 84% had a venous blood gas lactate test. 49% had a computed tomography (CT) and 35% had an X-ray (chest or abdomen). The average time to X-ray was 260 minutes; average time to CT was 324 minutes. Of those patients assessed, 59% had a documented discussion or review by a senior. A digital rectal examination was documented in 24% of patients. 49% of patients had a medical or surgical referral.

After presenting to triage nurses and doctors, we found marked improvements in rates of venous blood gas (100% vs 84%), CRP (100% vs 92%) and amylase (80% vs 64%). Time to X-ray was110 minutes (down from 260), and time to CT was 313 minutes (312). 90% of patients had a senior discussion or review documented (vs 59%), and 30% of patients had a PR (vs 24%).

Abdominal pain in older people is a common presentation to the emergency department, with nearly half of patients requiring referral to either a medical or surgical specialty. Of note, over half of patients underwent CT, yet this formed the main cause of delay. In this population, a high degree of diagnostic uncertainty and a relatively low radiation risk may prompt the question whether CT can be warranted prior to X-ray.

Conclusion

Our quality improvement project has demonstrated that simple teaching for doctors and nurses can improve the rates of important investigations of these patients. We plan to develop a pathway to bring about timely assessment and management for older adults presenting with abdominal pain in the hope of further improving their care.