Triaging to a Regional Acute Care Surgery Center: Distance Is Critical

Strategies and Recommendations to Improve Accessibility of Essential Surgery in Rural Settings in OECD Countries: A Scoping Review

BACKGROUND

The provision of essential and emergency surgical services presents complex challenges in remote areas. Equitable access has gained attention thanks to the significant work done by the Lancet Commission on Global Surgery (LCoGS). Although the focus was on low- and middle-income countries, developed countries also face challenges in providing equitable surgical care and, in fact, do not always meet the benchmarks set by the LCoGS yet still have acceptable outcomes. We sought to explore the current strategies aimed at improving and maintaining access to essential surgical care in rural and remote areas of OECD countries (Organization for Economic Co-operation and Development).

METHODS

We conducted a scoping review using MeSH terms. The search was performed on MEDLINE and EMBASE databases and was limited to English sources published between 1946 and January 10, 2025.

ELIGIBILITY CRITERIA

Any strategy or intervention aimed at improving and maintaining timely access to essential surgeries in rural and remote areas of OECD countries.

RESULTS

Six main categories of strategies were found: (1) resource distribution; (2) task sharing; (3) telemedicine; (4) surgical workforce; (5) training and education; and (6) prehospital system.

CONCLUSION

Recognizing that developed countries, in fact, do not always meet the benchmarks set by the LCoGS yet still have acceptable outcomes highlights that specific strategies are important contributors to the reduction of disparities between rural and urban outcomes. These strategies may be used in the study of surgical services in low- and middle-income countries.

Enrolling high-acuity emergency general surgery patients in a prospective longitudinal cohort study

Over 3 million patients are admitted to hospitals annually with high-acuity conditions mandating emergency abdominal or skin/soft-tissue operations. Patients with these high-acuity emergency general surgery (HA-EGS) diseases experience significant morbidity and mortality, yet the quality-of-life impact on survivors is not well studied. Acuity, transfer patterns, and adverse social determinants of health documented in epidemiologic studies are cited reasons for inability to measure patient-reported outcomes among HA-EGS survivors. We conducted a feasibility study to understand facilitators/barriers to conducting prospective studies of changes in quality of life after surviving HA-EGS. From September 2019 to April 2021, we collected baseline (preadmission) and 30/60 days' postsurgery data on activities of daily living, depression, self-efficacy, resilience, pain, work limitations, social support, and substance use from patients who enrolled in the study during index hospitalization. One hundred patients consented to participate (71.9% enrollment rate). The retention rate was 65.9% for 30-day follow-up telephone calls and 53.8% for 60-day follow-up calls. Median time needed to complete each time point remained under 25 minutes. Patients with a longer length of stay and nicotine users had higher odds of not completing their 30-day interview, while those with systemic complications had higher odds of not completing their 60-day interview. These results lay the foundation for future patient-reported outcome studies.

Interhospital transfer (IHT) in emergency general surgery patients (EGS): A scoping review

Background/Aims of study

Interhospital transfer of emergency general surgery patients continues to rise, and no system for transfer of emergency general surgery patients exists. This has major implications for cost of care and patient experience. We performed a scoping review to understand outcomes related to transfer and the associated factors and to identify any opportunities for improvement.

Methods

Studies involving emergency general surgery patients with interhospital transfer were identified by searching OVID MEDLINE, EMBASE, Cochrane Library, and Scopus. There were 1,785 records identified. After duplicates were removed, there were 1,303 articles screened in the initial phase. Fifty-eight articles were included in the second phase. Eventually, 21 articles were included in the review. Thirty-seven articles were removed during the full-text screening phase due to the following: wrong publication type (2), wrong population (8), abstract (11), outside the United States (3), and wrong study design (6).

Results

Transferred patients had a higher mortality rate, were older, were more likely to be male and to undergo reoperation, and had higher resource utilization compared to patients who were not transferred. All emergency general surgery patients had a high burden of chronic disease. Unnecessary transfer, typically defined by lack of intervention and discharge within 72 hours, was reported to be 8.8% to 19%.

Conclusion

Emergency general surgery patients have a high rate of comorbidities. Limited physiologic status information prior to patient transfer limits understanding of the necessity for transfer. Areas for improvement include assigning a physiologic status for all patients and utilizing telehealth. More detailed information needs to be captured to determine the appropriateness of transfer.

Distance travelled to hospital for emergency laparotomy and the effect of travel time on mortality: cohort study

OBJECTIVES

To evaluate whether distance and estimated travel time to hospital for patients undergoing emergency laparotomy is associated with postoperative mortality.

DESIGN

National cohort study using data from the National Emergency Laparotomy Audit.

SETTING

171 National Health Service hospitals in England and Wales.

PARTICIPANTS

22 772 adult patients undergoing emergency surgery on the gastrointestinal tract between 2013 and 2016.

MAIN OUTCOME MEASURES

Mortality from any cause and in any place at 30 and 90 days after surgery.

RESULTS

Median on-road distance between home and hospital was 8.4 km (IQR 4.7-16.7 km) with a median estimated travel time of 16 min. Median time from hospital admission to operating theatre was 12.7 hours. Older patients live on average further from hospital and patients from areas of increased socioeconomic deprivation live on average less far away.We included estimated travel time as a continuous variable in multilevel logistic regression models adjusting for important confounders and found no evidence for an association with 30-day mortality (OR per 10 min of travel time=1.02, 95% CI 0.97 to 1.06, p=0.512) or 90-day mortality (OR 1.02, 95 % CI 0.97 to 1.06, p=0.472).The results were similar when we limited our analysis to the subgroup of 5386 patients undergoing the most urgent surgery. 30-day mortality: OR=1.02 (95% CI 0.95 to 1.10, p=0.574) and 90-day mortality: OR=1.01 (95% CI 0.94 to 1.08, p=0.858).

CONCLUSIONS

In the UK NHS, estimated travel time between home and hospital was not a primary determinant of short-term mortality following emergency gastrointestinal surgery.

Association between operating room access and mortality for life-threatening general surgery emergencies

BACKGROUND

Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals.

METHODS

In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables.

RESULTS

Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1).

CONCLUSION

Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence.

LEVEL OF EVIDENCE

Therapeutic, level III.

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.

Management of acute appendicitis in an acute surgical unit: a cost analysis

BACKGROUND

The acute surgical unit (ASU) model of acute general surgery care offers efficient patient assessment, improved clinical outcomes and has been demonstrated to be cost-efficient. Despite this, the management of acute appendicitis in our ASU was found to be highly cost-negative. This study sought to identify the drivers of increased cost.

METHODS

A retrospective cost analysis of all patients with uncomplicated acute appendicitis in 2016 was undertaken to investigate the drivers of increased cost. The patient-level costing approach was used to assign cost to patients.

RESULTS

The ASU management of uncomplicated appendicitis was found to have made a net loss of $625 000 in 2016. This study identified that the three largest cost drivers in appendicitis care were hospital overheads, bed day length of admission cost and operating theatre costs. Radiology, pathology and pharmacy costs did not affect total cost significantly.

CONCLUSION

Two key targets for improvement were identified. First, reduced theatre turnaround times will allow more efficient theatre utilization. Second, improved after-hours and weekend theatre availability will reduce preoperative waiting time-related cost.

Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis

Importance

Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood.

Objective

To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging.

Design, Setting, and Participants

A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached.

Interventions

Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS.

Main Outcomes and Measures

We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access).

Results

Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities.

Conclusions and Relevance

Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka

The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.