Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa

Background. Acute appendicitis in rural South Africa is associated with significant morbidity due to prolonged delays before definitive surgical care. Objective. This audit aimed to quantify the delay in our healthcare system. Methods. From September 2010 to September 2012, all patients with confirmed acute appendicitis were interviewed and asked about the onset of symptoms and subsequent events in the disease process. Events before and after contact with the healthcare system were referred to as the pre-hospital or behavioural domain and the in-hospital or assessment domain, respectively. Results. Of the 500 patients, 350 (70.0%) experienced a delay of >48 hours from onset of symptoms to definitive surgical care. The mean time before treatment for this group was 5 days (range 3-7), while the mean for the group without delay was 1.6 days (range 1-2) (p<0.0001). Of 463 delays, 291 were in the behavioural domain and 172 in the assessment domain; 178 patients (50.9%) experienced delay in the behavioural domain only, 59 (16.9%) in the assessment domain only, and 113 (32.2%) in both domains. The mean ambulance transport time from the district hospital to the regional hospital was 4.9 hours. Conclusion. There are barriers that prevent patients with acute appendicitis from accessing care. There are also prolonged delays within the system once care has been accessed. Both these sources of delay need to be addressed by quality improvement programmes.