1
|
Rushing AP, Strassels SA, Ricci KB, Daniel VT, Ingraham AM, Paredes AZ, Diaz A, Oslock WM, Baselice HE, Heh VK, Santry HP. In-house intensivist presence does not affect mortality in select emergency general surgery patients. J Trauma Acute Care Surg 2021; 91:719-727. [PMID: 34238856 DOI: 10.1097/ta.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. METHODS Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. RESULTS We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. CONCLUSION Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. LEVEL OF EVIDENCE Therapeutic, level III.
Collapse
Affiliation(s)
- Amy P Rushing
- From the Department of Surgery-Trauma (A.P.R.), University Hospitals, Cleveland; Department of Surgery (S.A.S., A.Z.P., A.D., H.E.B., V.K.H.), Ohio State University Wexner Medical Center; Department of Surgery (K.B.R.), Johns Hopkins Medical School, Baltimore, MD; Department of Surgery (W.M.O.), University of Alabama, Birmingham, AL; Consulting Studio (H.P.S.), NBBJ Design LLC, Columbus, OH; Department of Trauma Surgery (H.P.S.), Kettering Medical Center, Kettering, OH; Center for Surgical Health Assessment, Research and Policy (S.A.S., K.B.R., A.Z.P., A.D., H.E.B., V.K.H., H.P.S.), Ohio State University, Columbus, Ohio; Department of Dermatology (V.T.D.), University of Massachusetts Medical School, Worcester MA; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Santry HP, Strassels SA, Ingraham AM, Oslock WM, Ricci KB, Paredes AZ, Heh VK, Baselice HE, Rushing AP, Diaz A, Daniel VT, Ayturk MD, Kiefe CI. Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach. BMC Med Res Methodol 2020; 20:247. [PMID: 33008294 PMCID: PMC7532630 DOI: 10.1186/s12874-020-01096-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).
Collapse
Affiliation(s)
- Heena P. Santry
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 614, Columbus, OH 43210 USA
| | - Scott A. Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI USA
| | - Wendelyn M. Oslock
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Kevin B. Ricci
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Anghela Z. Paredes
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Victor K. Heh
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Holly E. Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Amy P. Rushing
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Adrian Diaz
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Vijaya T. Daniel
- Department of Surgery, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - M. Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| |
Collapse
|
3
|
Oslock WM, Paredes AZ, Baselice HE, Rushing AP, Ingraham AM, Collins C, Ricci KB, Daniel VT, Diaz A, Heh VM, Strassels SA, Santry HP. Women surgeons and the emergence of acute care surgery programs. Am J Surg 2019; 218:803-808. [PMID: 31345501 DOI: 10.1016/j.amjsurg.2019.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly. METHODS From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi-squared tests, then used regression models to measure odds of ACS relative to the proportion of women. RESULTS 779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with <200 beds. ACS had a higher median proportion of women surgeons (17%) compared to non-ACS (0%). CONCLUSION Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by more recently trained surgeons. SUMMARY Using a national survey of Emergency General Surgery (EGS) hospitals, we sought to examine predictors of women surgeons in EGS generally, and acute care surgery (ACS) particularly. We found that 779 (50.4%) hospitals had zero women surgeons. Women were more likely to be among EGS surgeons at hospitals with ACS models. Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by a higher proportion of newly trained surgeons.
Collapse
Affiliation(s)
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | | | - Courtney Collins
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Vijaya T Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Victor M Heh
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA.
| |
Collapse
|
4
|
Ricci KB, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Diaz A, Heh VK, Baselice HE, Oslock WM, Strassels SA, Santry HP. The association between self-declared acute care surgery services and operating room access: Results from a national survey. J Trauma Acute Care Surg 2019; 87:898-906. [PMID: 31205221 DOI: 10.1097/ta.0000000000002394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access. CONCLUSION The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery. LEVEL OF EVIDENCE Therapeutic, Level III.
Collapse
Affiliation(s)
- Kevin B Ricci
- From the Department of Surgery (K.B.R., A.P.R., A.Z.P., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Center for Surgical Health Assessment, Research and Policy (SHARP) (K.B.R., A.P.R., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Ohio State Wexner Medical Center, Columbus, Ohio; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; Department of Surgery (V.T.D.), University of Massachusetts Medical School, Worcester, Massachusetts; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|