The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter

Cost-effectiveness and clinical outcomes comparison between noninvasive ventilation and high-flow nasal cannula use in patients with multiple rib fractures

BACKGROUND

Patients with multiple rib fractures often require advanced respiratory support to prevent intubation and associated morbidity. Noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) are commonly used, but direct comparisons of clinical outcomes and cost-effectiveness remain limited. This study aimed to compare NIV versus HFNC using a large, nationwide US database.

METHODS

This retrospective cohort study used the 2020-2021 National Inpatient Sample database to identify adult trauma patients (18-89 years) with two or more rib fractures who received either NIV or HFNC without prior intubation. To focus on isolated thoracic injuries, patients with significant injuries elsewhere (Abbreviated Injury Scale score ≥3) or who died within 24 hours were excluded. Inverse probability of treatment of weighting was used to balance patient characteristics, including demographics, comorbidities, and injury severity. Primary outcomes included mortality, tracheostomy, pulmonary complications, and intubation rates. Hospital length of stay and total costs were also assessed. Cost-effectiveness analyses were conducted with intubation avoidance as the effectiveness measure, and a willingness-to-pay threshold of US $50,000 per effectiveness unit was used.

RESULTS

After adjustment, the NIV group demonstrated significantly better outcomes compared with HFNC, including lower mortality (11.4% vs. 17.0%, p = 0.007) and tracheostomy (1.2% vs. 3.1%, p = 0.006), and fewer pulmonary complications. Although intubation rates were not statistically different (12.0% vs. 15.6%, p = 0.085), the HFNC group had longer length of stay (13 vs. 10 days, p < 0.001) and incurred higher costs (US $42,505 vs. US $32,024, p < 0.001). Cost-effectiveness analysis revealed that NIV dominated HFNC, yielding better outcomes at lower costs.

CONCLUSION

Among patients with multiple rib fractures, NIV yielded superior clinical outcomes, shortened hospital stays, and reduced costs compared with HFNC. These findings suggest that NIV may be a more cost-effective and clinically advantageous choice.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Impact of frailty on outcomes following emergency laparotomy: a retrospective analysis across diverse clinical conditions

PURPOSE

Emergency laparotomy (EL) encompasses procedures of varying complexity and urgency, undertaken in different clinical scenarios, leading to different risks of morbidity and mortality. We hypothesized that the increased mortality and longer postoperative length of stay (LoS) observed in frail patients are related to differences in indication for operation, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group.

METHODS

This retrospective cohort study analysed patients entered into the National Emergency Laparotomy Audit database between January 1, 2018, and June 15, 2021, in Oxford. The primary outcome was 180-day survival analysed using multivariable Cox regression. The secondary outcomes, delay to surgery (DtS) and postoperative LoS, were analysed using logarithmically transformed multivariable linear regression.

RESULTS

Of the 803 patients analysed, 396 (49.3%) were male. The median age was 66, and 337 (42%) were living with at least very mild frailty. Mortality hazard ratios for Clinical Frailty Scale grades 4 (3.93, 95% CI 1.89-8.20), 5 (5.86, 95% CI 2.87-11.97), and 6-7 (14.17, 95% CI 7.33-27.40) were not confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Frail patients experienced a 1.38-fold longer DtS and a 1.24-fold longer postoperative LoS, even after adjusting for indication, sepsis, intraperitoneal soiling, malignancy status, and DtS.

CONCLUSION

Our results indicate that frail patients have a poorer prognosis and longer postoperative LoS, independent of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. Patient frailty is also associated with longer DtS.

Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis

BACKGROUND

Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort.

METHODS

All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest.

RESULTS

Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (β + 1.04 days, CI + .91-1.17) and greater costs (β+$3,490, CI + 2840-4140).

DISCUSSION

While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Deaths After Readmissions are Mostly Attributable to Failure-to-Rescue in EGS Patients

INTRODUCTION

We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR.

METHODS

A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression.

RESULTS

Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR.

DISCUSSION

Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.

Impact of Procedure Risk vs Frailty on Outcomes of Elderly Patients Undergoing Emergency General Surgery: Results of a National Analysis

BACKGROUND

The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty.

STUDY DESIGN

Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes.

RESULTS

A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty.

CONCLUSIONS

Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.

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.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

BACKGROUND

European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS

Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS

Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS

This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Contemporary Assessment of Adhesiolysis and Resection for Adhesive Small Bowel Obstruction in the State of New York

BACKGROUND

Adhesive small bowel obstruction (aSBO) is a common surgical problem, with some advocating for a more aggressive operative approach to avoid recurrence. Contemporary outcomes in a real-world setting were examined.

STUDY DESIGN

A retrospective cohort study was performed using the New York Statewide Planning and Research Cooperative database to identify adults admitted with aSBO, 2016-2020. Patients were stratified by the presence of inflammatory bowel disease (IBD) and cancer history. Diagnoses usually requiring resection were excluded. Patients were categorized into four groups: non-operative, adhesiolysis, resection, and 'other' procedures. In-hospital mortality, major complications, and odds of undergoing resection were compared.

RESULTS

58,976 patients were included. 50,000 (84.8%) underwent non-operative management. Adhesiolysis was the most common procedure performed (n = 4,990, 8.46%), followed by resection (n = 3,078, 5.22%). In-hospital mortality in the lysis and resection groups was 2.2% and 5.9% respectively. Non-IBD patients undergoing operation on the day of admission required intestinal resection 29.9% of the time. Adjusted odds of resection were highest for those with a prior aSBO episode (OR 1.29 95%CI 1.11-1.49), delay to operation ≥3 days (OR1.78 95%CI 1.58-1.99), and non-New York City (NYC) residents being treated at NYC hospitals (OR1.57 95%CI 1.19-2.07).

CONCLUSION

Adhesiolysis is currently the most common surgery for aSBO, however nearly one-third of patients will undergo a more extensive procedure, with an increased risk of mortality. Innovative therapies are needed to reduce the risk of resection.

Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay

BACKGROUND

Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy).

METHODS

Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital.

RESULTS

A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided t-test (p = 0.05).

CONCLUSION

Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.

A National Analysis of Racial and Sex Disparities Among Interhospital Transfers for Emergency General Surgery Patients and Associated Outcomes

INTRODUCTION

Studies focusing on Emergency General Surgery (EGS) and Interhospital Transfer (IHT) and the association of race and sex and morbidity and mortality are yet to be conducted. We aim to investigate the association of race and sex and outcomes among IHT patients who underwent emergency general surgery.

METHODS

A retrospective review of adult patients who were transferred prior to EGS procedures using the National Surgery Quality Improvement Project from 2014 to 2020. Multivariable logistic regression models were used to compare outcomes (readmission, major and minor postoperative complications, and reoperation) between interhospital transfer and direct admit patients and to investigate the association of race and sex for adverse outcomes for all EGS procedures. A secondary analysis was performed for each individual EGS procedure.

RESULTS

Compared to patients transferred directly from home, IHT patients (n = 28,517) had higher odds of readmission [odds ratio (OR): 1.004, 95% confidence interval (CI) (1.002-1.006), P < 0.001], major complication [adjusted OR: 1.119, 95% CI (1.117-1.121), P < 0.001), minor complication [OR: 1.078, 95% CI (1.075-1.080), P < 0.001], and reoperation [OR: 1.014, 95% CI (1.013-1.015), P < 0.001]. In all EGS procedures, Black patients had greater odds of minor complication [OR 1.041, 95% CI (1.023-1.060), P < 0.001], Native Hawaiian and Pacific Islander patients had greater odds of readmission [OR 1.081, 95% CI (1.008-1.160), P = 0.030], while Asian and Hispanic patients had lower odds of adverse outcome, and female patients had greater odds of minor complication [OR 1.017, 95% CI (1.008-1.027), P < 0.001].

CONCLUSIONS

Procedure-specific racial and sex-related disparities exist in emergency general surgery patients who underwent interhospital transfer. Specific interventions should be implemented to address these disparities to improve the safety of emergency procedures.

Timing, triage, and mode of emergency general surgery interfacility transfers in the United States: A scoping review

ABSTRACT

Interfacility transfer of emergency general surgery (EGS) patients continues to rise, especially in the context of ongoing system consolidation. This scoping review aims to identify and summarize the literature on triage, timing, and mode of interfacility emergency general surgery transfer. While common, EGS transfer systems are not optimized to improve outcomes or ensure value-based care. We identified studies investigating emergency general surgery interfacility transfer using Ovid Medline, EMBASE, and Cochrane Library between 1990 and 2022. English studies that evaluated EGS interfacility timing, triage or transfer mode were included. Studies were assessed by two independent reviewers. Studies were limited to English-language articles in the United States. Data were extracted and summarized with a narrative synthesis of the results and gaps in the literature. There were 423 articles identified, of which 66 underwent full-text review after meeting inclusion criteria. Most publications were descriptive studies or outcomes investigations of interfacility transfer. Only six articles described issues related to the logistics behind the interfacility transfer and were included. The articles were grouped into the predefined themes of transfer timing, triage, and mode of transfer. There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer. Further research should focus on better understanding which populations of patients require expedited transfer and by what mode. The lack of high-level data supports the need for robust investigations into interfacility transfer processes to optimize triage using scarce resources and optimized value-based care.

A comprehensive analysis of 30-day readmissions after emergency general surgery procedures: Are risk factors modifiable?

BACKGROUND

Modifiable risk factors associated with procedure-related 30-day readmission after emergency general surgery (EGS) have not been comprehensively studied. We set out to determine risk factors associated with EGS procedure-related 30-day unplanned readmissions.

METHODS

A retrospective cohort study was conducted using the National Surgical Quality Improvement Project database (2013-2019). It included nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Data on patient characteristics, admission status, procedure risk, hospital length of stay, and discharge disposition were analyzed by multivariate logistic regression.

RESULTS

A total of 312,862 patients were included (16,306 procedure-related 30-day readmissions [5.2%]). Thirty-day readmission patients were older, had higher American Association of Anesthesiology scores, were more often underweighted or markedly obese, and were more frequently presented with sepsis. Risk factors associated with EGS procedure-related 30-day unplanned readmissions included age older than 40 years (adjusted odds ratio [AOR], 1.15), American Association of Anesthesiology ≥3 (AOR, 1.41), sepsis present at the time of surgery (AOR, 1.84), body mass index <18 kg/m 2 (AOR, 1.16), body mass index ≥40 kg/m 2 (AOR, 1.12), high-risk procedures (AOR, 1.51), LOS ≥4 d (AOR, 2.04), and discharge except to home (AOR, 1.33). Thirty-day readmissions following low-risk procedures occurred at a median of 5 days (interquartile range, 2-11 days) and 6 days (interquartile range, 3-11 days) after high-risk procedures. Surgical site infections, postoperative sepsis, wound disruption, and thromboembolic events were more prevalent in the 30-day readmission group. Mortality rate was fourfold higher in the 30-day readmission group (2.4% vs. 0.6%).

CONCLUSION

We identified several unmodifiable patients and EGS disease-related factors associated with 30-day unplanned readmissions. Readmissions could be potentially reduced by the implementation of a postdischarge surveillance systems between hospitals and postdischarge destination facilities, leveraging telehealth and outpatient care.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center

BACKGROUND

The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints.

METHODS

An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality.

RESULTS

There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively.

CONCLUSION

Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.