Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care

Demystifying the association of center-level operative trauma volume and outcomes of emergency general surgery

BACKGROUND

Recent studies have demonstrated a positive volume-outcome relationship in emergency general surgery. Some have advocated for the sub-specialization of emergency general surgery independent from trauma. We hypothesized inferior clinical outcomes of emergency general surgery with increasing center-level operative trauma volume, potentially attributable to overall hospital quality.

METHODS

Adults (≥18 years) undergoing complex emergency general surgery operations (large and small bowel resection, repair of perforated peptic ulcer, lysis of adhesions, laparotomy) were identified in the 2016 to 2020 Nationwide Readmissions Database. Multivariable risk-adjusted models were developed to evaluate the association of treatment at a high-volume trauma center (reference: low-volume trauma center) with clinical and financial outcomes after emergency general surgery. To evaluate hospital quality, mortality among adult hospitalizations for acute myocardial infarction was assessed by hospital trauma volume.

RESULTS

Of an estimated 785,793 patients undergoing a complex emergency general surgery operation, 223,116 (28.4%) were treated at a high-volume trauma center. Treatment at a high-volume trauma center was linked to 1.19 odds of in-hospital mortality (95% confidence interval 1.12-1.27). Although emergency general surgery volume was associated with decreasing predicted risk of mortality, increasing trauma volume was linked to an incremental rise in the odds of mortality after emergency general surgery. Secondary analysis revealed increased mortality for admissions for acute myocardial infarction with greater trauma volume.

CONCLUSION

We note increased mortality for emergency general surgery and acute myocardial infarction in patients receiving treatment at high-volume trauma centers, signifying underlying structural factors to broadly affect quality. Thus, decoupling trauma and emergency general surgery services may not meaningfully improve outcomes for emergency general surgery patients. Our findings have implications for the evolving specialty of emergency general surgery, especially for the safety and continued growth of the acute care surgery model.

Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative

BACKGROUND

Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements.

METHODS

We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits.

RESULTS

Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals.

CONCLUSION

A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries

IMPORTANCE

Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown.

OBJECTIVE

To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022.

EXPOSURES

The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%).

MAIN OUTCOMES AND MEASURES

The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings.

RESULTS

There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves.

CONCLUSIONS AND RELEVANCE

AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.

The physiology of failure: Identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record

BACKGROUND

Emergency general surgery (EGS) patients have increased mortality risk compared with elective counterparts. Recent studies on risk factors have largely used national data sets limited to administrative data. Our aim was to examine risk factors in an integrated regional health system EGS database, including clinical and administrative data, hypothesizing that this novel process would identify clinical variables as important risk factors for mortality.

METHODS

Our nine-hospital health system's billing data were queried for EGS International Classification of Disease codes between 2013 and 2018. Codes were grouped by diagnosis, and urgent or emergent encounters were included and merged with electronic medical record clinical data. Outcomes assessed were inpatient and 1-year mortality. Standard and multivariable statistics evaluated factors associated with mortality.

RESULTS

There were 253,331 EGS admissions with 3.6% inpatient mortality rate. Patients who suffered inpatient and 1-year mortality were older, more likely to be underweight, and have neutropenia or elevated lactate. On multivariable analysis for inpatient mortality: age (odds ratio [OR], 1.7-6.7), underweight body mass index (OR, 1.6), transfer admission (OR, 1.8), leukopenia (OR, 2.0), elevated lactate (OR, 1.8), and ventilator requirement (OR, 7.1) remained associated with increased risk. Adjusted analysis for 1-year mortality demonstrated similar findings, with highest risk associated with older age (OR, 2.8-14.6), underweight body mass index (OR, 2.3), neutropenia (OR, 2.0), and tachycardia (OR, 1.7).

CONCLUSION

After controlling for patient and disease characteristics available in administrative databases, clinical variables remained significantly associated with mortality. This novel yet simple process allows for easy identification of clinical data points imperative to the study of EGS diagnoses that are critical in understanding factors that impact mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Socioeconomic disadvantage is associated with greater mortality after high-risk emergency general surgery

BACKGROUND

Socioeconomic disadvantage is associated with worse outcomes after elective surgery, but the effect on emergency general surgery (EGS) remains unclear. We examined the association of socioeconomic disadvantage and outcomes after EGS procedures and investigated whether admission to hospitals with comprehensive clinical and social resources mitigated this effect.

METHODS

Adults undergoing 1 of the 10 most burdensome high- and low-risk EGS procedures were identified in six 2014 State Inpatient Databases. Socioeconomic disadvantage was assessed using Area Deprivation Index (ADI) of patient residence. Multivariable logistic regression models adjusting for patient and hospital factors were used to evaluate the association between ADI quartile (high >75 percentile vs. low <25 percentile), and 30-day readmission, in-hospital mortality, and discharge disposition. Effect modification between ADI and (a) level 1 trauma center and (b) safety-net hospital status was tested.

RESULTS

A total of 103,749 patients were analyzed: 72,711 low-risk (70.1%) and 31,038 high-risk procedures (29.9%). Patients from neighborhoods with high socioeconomic disadvantage had a higher proportion with ≥3 comorbidities (41.9% vs. 32.0%), minority race/ethnicity (66.3% vs. 42.4%), and Medicaid (28.8% vs. 14.7%) and were less likely to be treated at level 1 trauma centers (18.3% vs. 27.7%; p < 0.001 for all). Adjusting for competing factors, high socioeconomic disadvantage was associated with increased in-hospital mortality after high-risk procedures (odd ratio, 1.30; 95% confidence interval, 1.01-1.66; p = 0.04) and higher odds of non-home discharge (odd ratio, 1.15; 95% confidence interval, 1.02-1.30; p = 0.03) for low-risk procedures. Socioeconomic disadvantage was not associated with 30-day readmission for either procedure group. Level 1 trauma status and safety-net hospital did not meaningfully mitigate effect of ADI for any outcome.

CONCLUSION

Socioeconomic disadvantage is associated with increased mortality after high-risk procedures and higher odds of non-home discharge after low-risk procedures. This effect was not mitigated by either level 1 trauma or safety-net hospitals. Interventions that specifically address the needs of socially vulnerable communities will be required to significantly improve EGS outcomes for this population.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, level III.

Emergency general surgery transfer to lower acuity facility: The role of right-sizing care in emergency general surgery regionalization

BACKGROUND

Regionalization of emergency general surgery (EGS) has primarily focused on expediting care of high acuity patients through interfacility transfers. In contrast, triaging low-risk patients to a nondesignated trauma facility has not been evaluated. This study evaluates a 16-month experience of a five-surgeon team triaging EGS patients at a tertiary care, Level I trauma center (TC) to an affiliated community hospital 1.3 miles away.

METHODS

All EGS patients who presented to the Level I TC emergency department from January 2020 to April 2021 were analyzed. Patients were screened by EGS surgeons covering both facilities for transfer appropriateness including hemodynamics, resource need, and comorbidities. Patients were retrospectively evaluated for disposition, diagnosis, comorbidities, length of stay, surgical intervention, and 30-day mortality and readmission.

RESULTS

Of 987 patients reviewed, 31.5% were transferred to the affiliated community hospital, 16.1% were discharged home from the emergency department, and 52.4% were admitted to the Level I TC. Common diagnoses were biliary disease (16.8%), bowel obstruction (15.7%), and appendicitis (14.3%). Compared with Level I TC admissions, Charlson Comorbidity Index was lower (1.89 vs. 4.45, p < 0.001) and length of stay was shorter (2.23 days vs. 5.49 days, p < 0.001) for transfers. Transfers had a higher rate of surgery (67.5% vs. 50.1%, p < 0.001) and lower readmission and mortality (8.4% vs. 15.3%, p = 0.004; 0.6% vs. 5.0%, p < 0.001). Reasons not to transfer were emergency evaluation, comorbidity burden, operating room availability, and established care. No transfers required transfer back to higher care (under-triage). Bed days saved at the Level I TC were 693 (591 inpatients). Total operating room minutes saved were 24,008 (16,919, between 7:00 am and 5:00 pm).

CONCLUSION

Transfer of appropriate patients maintains high quality care and outcomes, while improving operating room and bed capacity and resource utilization at a tertiary care, Level I TC. Emergency general surgery regionalization should consider triage of both high-risk and low-risk patients.

LEVEL OF EVIDENCE

Prospective comparative cohort study, Level II.

Reducing Health Care Burden of Emergency General Surgery with a 24-Hour Dedicated Emergency General Surgery Service

BACKGROUND

Emergency general surgery (EGS) diagnoses account for 11% of surgical admissions and 50% of surgical mortality. In this population, 7 specific operations are associated with 80.3% of deaths, 78.9% of complications, and 80.2% of hospital costs. In 2016, our institution established a comprehensive in-house EGS service. Herein, we hypothesize that formation of a dedicated EGS service is associated with a significant reduction in morbidity for patients undergoing the most common EGS procedures.

METHODS

All patients undergoing one of the most common EGS procedures within 2 days of admission were identified from 1/1/2013 to 5/9/2019 via a retrospective chart review. Patients were cohorted as pre- and post-EGS implementation. The primary outcome measure was the overall complication rate. Secondary endpoints included mortality, individual complication rate, time to operation, overnight operation, and length of stay. Finally, both cohorts were benchmarked to national outcomes.

RESULTS

718 patients met inclusion criteria (pre-EGS = 409 and post-EGS = 309). Overall complication rate decreased significantly (19.8% vs 13.9%, P = .0387) and overnight operations increased significantly in the post-EGS group (7.8%-16.5%, P = .0003). Pre-EGS complications were higher than national data in all but 1 procedure group, whereas post-EGS complications rates were lower in all but 2 categories.

DISCUSSION

Implementation of a dedicated EGS service line was associated with a significant decrease in complication rate among the most complication-prone EGS procedures. Number of operations within 24 hours did not increase significantly; however, overnight operations did increase. Our results indicate that establishing a service-specific EGS line is reasonable and beneficial.

High Resource Utilization in Emergent Versus Elective General Surgery

BACKGROUND

In an era of pay for performance metrics, we sought to increase understanding of factors driving high resource utilization (HRU) in emergent (EGS) versus same-day elective (SDGS) general surgery patients.

METHODS

General surgery procedures from the 2016 ACS-NSQIP public use file were grouped according to the first four digits of the primary procedure CPT code. Groups having at least 100 of both elective and emergent cases were included (22 groups; 83,872 cases). HRU patients were defined as those in-hospital >7D, returned to the OR, readmitted, and/or had morbidity likely requiring an intensive care unit (ICU)stay. Independent NSQIP predictors of HRU were identified through forward regression; P for entry < 0.05, for exit > 0.10.

RESULTS

Of all patients, 33% were HRU. The three highest HRU procedures (total colectomy, enterolysis, and ileostomy) comprised a higher proportion of EGS than SDGS cases (10.3 versus 2.6%, P < 0.001). The duration of operation was 40 Min lower in EGS after adjustment. Thirty-nine of the remaining 40 HRU predictors were higher in EGS including preoperative SIRS/Sepsis (50 versus 2%), ASA classification IV-V (31 versus 5%), albumin <3.5 g/dL (40 versus 12%), transfers (26 versus 2%, P's < 0.001), septuagenarians (35 versus 25%) and disseminated cancer (6.3 versus 4.8%, P's < 0.001); while sex did not differ. After adjustment, EGS patients remained more likely to be HRU (odds ratio 2.5, 95% CI 2.4 - 2.6, P < 0.001).

CONCLUSIONS

EGS patients utilize significantly more resources than SDGS patients above what can be adjusted for in the clinically robust ACS-NSQIP dataset. Distinctive payment and value-based performance models are necessary for EGS.

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

Importance

Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood.

Objective

To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes.

Design, Setting, and Participants

This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021.

Exposures

Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality).

Main Outcomes and Measures

The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes.

Results

Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27).

Conclusions and Relevance

In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.

Does the ‘halo effect’ of trauma center verification extend to severe postpartum hemorrhage? A four-year retrospective review of level 1 trauma centers in the United States

Introduction

Designated high-quality trauma services have been shown to improve outcomes of trauma patients by virtue of access to specialized personnel and resources. It remains unclear if a ‘halo effect’ extends these benefits more generally to non-trauma populations. Obstetric patients who develop severe postpartum hemorrhage often require close attention in intensive care units and utilize more resources. Given the overlapping needs between trauma and obstetric patients, we hypothesize that the ‘halo effect’ might extend to patients with severe postpartum hemorrhage.

Methods

The Nationwide Inpatient Sample for years 2008 to 2011 was queried. Patients with severe postpartum hemorrhage were identified as those requiring transfusion, hysterectomy, or uterine repair. After stratifying by level 1 trauma center versus non-level 1 trauma center status, unadjusted univariate comparisons were made. Adjusted odds ratio of end-organ failure and death were analyzed using multivariable logistic regression.

Results

A total of 11,135 patients were identified with severe postpartum hemorrhage. The majority were hospitalized at non-level 1 trauma centers rather than level 1 trauma centers (71.4% vs. 28.6%). Patients at non-level 1 trauma centers were younger, more likely to be white, admitted electively, insured, and healthier with a lower comorbidity index. There was no significant difference in rates of mortality or organ failure. However, after adjustment for differences in comorbidity index, race, and emergency admission, patients at non-level 1 trauma centers had a significantly higher risk of respiratory failure (odds ratio, 1.27; 95% confidence interval, 1.01–1.59).

Conclusions

These findings suggest that the outcomes of obstetric patients with severe postpartum hemorrhage admitted in level 1 trauma centers are not overall significantly different when compared to those in non-level 1 trauma centers. However, after adjusting for baseline characteristics, there was a reduced risk of respiratory failure in patients admitted to level 1 trauma centers.

Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry

BACKGROUND

The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes.

METHODS

A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases.

RESULTS

In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications.

CONCLUSIONS

National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.

Hospital Location and Socioeconomic Disadvantage of Emergency General Surgery Patients

BACKGROUND

Emergency general surgery (EGS) patients are more socioeconomically vulnerable than elective counterparts. We hypothesized that a hospital's neighborhood disadvantage is associated with vulnerability of its EGS patients.

MATERIALS AND METHODS

Area deprivation index (ADI), a neighborhood-level measure of disadvantage, and key characteristics of 724 hospitals in 14 states were linked to patient-level data in State Inpatient Databases. Hospital and EGS patient characteristics were compared across hospital ADI quartiles (least disadvantaged [ADI 1-25] "affluent," minimally disadvantaged [ADI 26-50] "min-da", moderately disadvantaged [ADI 51-75] "mod-da", and most disadvantaged [ADI 76-100] "impoverished") using chi² tests and multivariable regression.

RESULTS

Higher disadvantage hospitals are more often nonteaching (affluent = 38.9%, min-da = 53.5%, mod-da = 72.1%, and impoverished = 67.6%), nonaffiliated with medical schools (50%, 72.4%, 81.8%, and 78.8%), and in rural areas (3.3%, 9.2%, 31.2%, and 27.9%). EGS patients at higher disadvantage hospitals are more likely to be older (43.9%, 48.6%, 49.1%, and 46.6%), have >3 comorbidities (17.0%, 19.0%, 18.4%, and 19.3%), live in low-income areas (21.4%, 23.6%, 32.2%, and 42.5%), and experience complications (23.2%, 23.7%, 24.0%, and 25.2%). Rates of uninsurance/underinsurance were highest at affluent and impoverished hospitals (18.0, 16.4%, 17.7%, and 19.2%). Higher disadvantage hospitals serve fewer minorities (32.6%, 21.3%, 20.7%, and 24.0%), except in rural areas (2.9%, 6.7%, 6.5%, and 15.5%). In multivariable analyses, the impoverished hospital ADI quartile did not predict odds of serving as a safety-net or predominantly minority-serving hospital.

CONCLUSIONS

Hospitals in impoverished areas disproportionately serve underserved EGS patient populations but are less likely to have robust resources for EGS care or train future EGS surgeons. These findings have implications for measures to improve equity in EGS outcomes.

The Emergency surgery score (ESS) accurately predicts outcomes of emergency surgical admissions at a Saudi academic health center

BACKGROUND

The emergency surgery score (ESS) has emerged as a tool to predict outcomes in emergency surgery (EGS) patients. Our study examines the ability of ESS to predict outcomes in EGS admissions.

METHODS

All EGS admissions to King Saud University Medical City (KSUMC) from January 2017 to October 2019 were included. ESS was calculated for each patient. Correlations between ESS and 30-day mortality and complications were evaluated.

RESULTS

1607 patients were included. 30-day mortality rate was 2.2% while complication rate was 18.7%. Mortality increased as ESS increased, from 0.3% for ESS≤2, to 30.1% for ESS >10, with a c-statistic of 0.88. Complication rates were 2.2%, 40%, and 100% at ESS of 0, 6, and 15, respectively, with a c-statistic of 0.82.

CONCLUSIONS

ESS accurately predicted outcomes at our tertiary center. ESS could be useful in identifying high risk EGS admissions and in benchmarking quality of care across Saudi institutions.

Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments

BACKGROUND

Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States.

METHOD

We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital.

RESULTS

Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals.

CONCLUSION

Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.

Validation of the American Association for the Surgery of Trauma grading system for acute appendicitis severity

OBJECTIVE

The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking.

METHODS

Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison.

RESULTS

A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied.

CONCLUSION

Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes.

LEVEL OF EVIDENCE

Prospective/Epidemiologic, Level III.

The weekend effect - How can it be mitigated? Introduction of a consultant-delivered emergency general surgical service

Background

Poorer patient outcomes for emergency general surgery have been observed in patients admitted to hospital over the weekend. This paper reports the outcomes of a Consultant-delivered service model for weekend admissions and its impact for patients undergoing emergency laparotomy.

Methods

Operative data was analysed from a prospectively collected database over 5-years. Primary outcome measures were 30-day all-cause mortality and Clavien-Dindo class ≥2 morbidity. Secondary outcomes included time from admission to diagnostic imaging and time to surgery, post-operative length of stay and requirement for Intensive Care Unit admission.

Results

263 patients underwent an emergency laparotomy. Overall 30-day mortality was 4.6% and all-cause morbidity was 55.9%. The most common indications for laparotomy were mechanical small bowel obstruction (32.7%) and hollow viscus perforation (30.4%) of the 263 emergency laparotomies, 92 patients in the cohort were weekend admissions (Saturday or Sunday). There was no significant difference amongst patients admitted during the weekend in ASA grade, age, gender, or proportion of patients receiving a pre-operative computed tomography scan, when compared to those during the week. Compared to weekdays, weekend admission was not associated with a significant difference in mortality (5.3% and 3.3%, respectively p = 0.458), all-cause morbidity (p = 0.509), post-operative length of stay (p = 0.681), or Intensive Care Unit admission (p = 0.761).

Conclusion

A Consultant Surgeon delivered emergency service can avoid the poor patient outcomes associated with weekend admissions and the ‘weekend effect’.

•

Poorer patient outcomes have been observed in patients admitted during the weekend.

•

A Consultant Surgeon delivered model of service delivery ensures peri- and intra-operative Consultant presence for all emergency surgery.

•

Under this model, there was no weekend effect observed.

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume

BACKGROUND

Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC).

METHODS

Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume.

RESULTS

In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million).

CONCLUSION

Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value.

LEVEL OF EVIDENCE

Epidemiological, level III.

Twenty-year study of in-hospital and postdischarge mortality following emergency general surgical admission

Background

Emergency general surgery (EGS) patients have a higher mortality than those having elective surgery. Few studies have investigated changes in EGS-associated mortality over time or explored mortality rates after discharge. The aim of this study was to conduct a comprehensive, population-based analysis of mortality in EGS patients over a 20-year time frame.

Methods

This was a cross-sectional study of all adult EGS admissions in Scotland between 1996 and 2015. Data were obtained from national records. Co-morbidities were defined by Charlson Co-morbidity Index, and operations were coded by OPCS-4 classifications. Linear and multivariable logistic regression models were used to evaluate changes over time.

Results

Among 1 450 296 patients, the overall inpatient, 30-day, 90-day and 1-year mortality rates were 1·8, 3·8, 6·4 and 12·5 per cent respectively. Mortality was influenced by age at admission, co-morbidity, operation performed and date of admission (all P < 0·001), and improved with time on subgroup analysis by age, co-morbidity and operation status. Medium-term mortality was high: the 1-year mortality rate in patients aged over 75 years was 35·6 per cent. The 1-year mortality rate in highly co-morbid patients decreased from 75·1 to 57·1 per cent over the time frame of the study (P < 0·001).

Conclusion

Mortality after EGS in Scotland has reduced significantly over the past 20 years. This analysis of medium-term mortality after EGS admission demonstrates strikingly high rates, and postdischarge death rates are higher than is currently appreciated.

Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.

Laparoscopic Cholecystectomy is Safe Both Day and Night

BACKGROUND

It is reported that performing laparoscopic cholecystectomy (LC) at night leads to increased rates of complications and conversion to open. We hypothesize that it is safe to perform LC at night in appropriately selected patients.

MATERIALS AND METHODS

We performed a retrospective review of nonelective LC in adults at our institution performed between April 2007 and February 2015. We dichotomized the cases to either day or night.

RESULTS

Five thousand two hundred four patients underwent LC, with 4628 during the day and 576 at night. There were no differences in age, body mass index, American Society of Anesthesiologists class, race, insurance type, pregnancy rate, or white blood cell count. There were also no differences in the prevalence of hypertension, diabetes, or renal failure. However, daytime patients had higher median initial total bilirubin (0.6 [0.4, 1.3] versus 0.5 [0.3, 1.0] mg/dL, P = 0.002) and lipase (33 [24, 56] versus 30 [22, 42] U/L, P < 0.001) values. There was no difference in case length, estimated blood loss, rate of conversion to open, biliary complications, length of stay (LOS) after operation, unanticipated return to the hospital in 60 d, or 60-d mortality. Daytime patients spent more time in the hospital with longer median LOS before surgery (1 [1, 2] versus 1 [0, 2] d, P < 0.001) and median total LOS (3 [2, 4] versus 2 [1, 3] d, P < 0.001) compared with night patients.

CONCLUSIONS

At our institution, we perform LC safely during day or night. The lack of complications and shorter LOS justify performing LC at any hour.