Emergency General Surgery Patients Research Articles

Financial Toxicity in Emergency General Surgery: Novel Propensity-Matched Outcome Comparison.

Financial toxicity describes the harmful effect of individual treatment costs and fiscal burdens that have a compounding negative impact on outcomes in surgery. While this phenomenon has been widely studied in surgical oncology, the purpose of this study was to perform a novel exploration of the impact of financial toxicity in emergency general surgery (EGS) patients throughout the US. The Nationwide Readmissions Database for January and February 2018 was queried for all EGS patients aged 18 to 65 years. One-to-one propensity matching was performed with and without risk for financial toxicity. The primary outcome was mortality, and the secondary outcomes were venous thromboembolism (VTE), prolonged length of stay (LOS), and readmission within 30 days. There were 24,154 EGS patients propensity matched. The mortality rate was 0.2% (n = 39), and the rate of VTE was 0.5% (n = 113). With financial toxicity, there was no statistically significant difference for mortality (p = 0.08) or VTE (p = 0.30). The rate of prolonged LOS was 6.2% (n = 824), and the risk was increased with financial toxicity (risk ratio 1.24 [1.12 to 1.37]; p < 0.001). The readmission rate was 7.0% (n = 926), and the risk with financial toxicity was increased (risk ratio 1.21 [1.10 to 1.33]; p < 0.001). The mean count of comorbidities per patient per admission during readmission within 1 year with financial toxicity was 2.1 ± 1.9 versus 1.8 ± 1.7 without (p < 0.001). Despite little difference in the rate of mortality or VTE, EGS patients at risk for financial toxicity have an increased risk of readmission and longer LOS. Fewer comorbidities were identified at index admission than during readmission in patients at risk for financial toxicity. Future studies aimed at reducing this compounding effect of financial toxicity and identifying missed comorbidities have the potential to improve EGS outcomes.

Spatial access to Emergency General Surgery (EGS) services and EGS bypass behaviours in California

ABSTRACT Hospital bypass behaviours (i.e. people go to faraway hospitals instead of close ones) of Emergency General Surgery (EGS) patients may cause treatment delays and worsened health outcomes. This study aimed to find the associations between EGS bypass behaviours and spatial access to EGS services as well as other factors at the individual level and ZIP Code Tabulation Area (ZCTA) level in California. We used a gravity model to calculate spatial access to EGS services at the ZCTA level. A Bayesian hierarchical spatial model was used to access associated variables of EGS bypass while accounting for spatial autocorrelation. Results show that better spatial access to EGS hospitals was associated with lower likelihood of EGS bypass. Other factors such as rural–urban status, health insurance type and race/ethnicity were also related to EGS bypass behaviours. Besides, people with similar EGS bypass behaviours seemed to cluster together due to spatial effect. Our results have important implications for EGS resource allocation, utilization and EGS disparity alleviation.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients

IntroductionAlthough two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). Materials and methodsWe studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was “Not Needed” (medical management preferred) or “Not Recommended” (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. ResultsWe included 204 patients (60% female, median age 75 y), for whom an operation was “Not Needed” in 81% and “Not Recommended” in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the “Not Recommended” cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. ConclusionsNonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Impact of Rurality on Geriatric Emergency General Surgery Patients in New Hampshire.

Geriatric patients requiring emergency general surgery (EGS) have significant risk of morbidity and mortality. Rural patients face decreased access to care. We sought to characterize the EGS needs and impact of rurality for geriatric residents of New Hampshire. A retrospective cohort study of the New Hampshire Uniform Healthcare Facility Discharge Dataset, including patients 65 years and older with urgent/emergent admission who underwent 1 of 7 EGS procedures, grouped by urban or rural county of residence, discharged between 2012-2015. New Hampshire has 26 acute care hospitals: 10 (38.5%) are in urban counties and 16 (61.5%) are in rural counties. Thirteen (50.0%) are critical access hospitals (1 urban and 12 rural). Of 2,445 geriatric patient discharges, 40% of patients were from rural counties and were demographically similar to urban patients. Rural patients were more likely to present as a hospital transfer (15.4% vs 2.5%, p < 0.01), receive care at a critical access hospital (24.1% vs 1.0%, p < 0.01), receive care outside their home county (32.5% vs 12.8%, p < 0.01), and be transferred to another hospital after surgery. Rural and urban patients underwent similar procedures, with similar lengths of stay, cost of index hospitalization, and mortality. Rural geriatric patients in New Hampshire are more likely to receive care outside of their home county or be transferred to another hospital. Costs of care were similar but are likely underestimated for rural patients. There was no difference in unadjusted mortality. Further investigation is merited to determine the reasons for hospital transfer in the geriatric EGS population to evaluate which patients may benefit most from remaining close to home vs transferring to other facilities.

The butterfly effect: How an outpatient quality improvement project affected inpatient opioid's prescribing habits.

The aim of the study was to assess whether a quality improvement project focused on providers' education of responsible opioid prescribing, creating order sets to facilitate pre- and post-operative adjunct use, and decreasing the number of opioids prescribed following elective outpatient surgery affected opioid prescribing habits and the use of adjunct pain medication on the inpatient Emergency General Surgery (EGS) service. Inpatient EGS opioid prescribing habits following laparoscopic cholecystectomy, laparoscopic and open inguinal hernia repair, or open umbilical hernia repair during the pre- and post-Acute Care Surgery Division-Quality Improvement (QI) periods were recorded retrospectively. Demographics, type and dose of opioids, and non-opioid adjuncts prescribed were collected. Opioids were converted to oral morphine equivalents (OME). Pre- and post-QI data were compared. Post-QI discharge opioids prescribed were compared to reported use of opioids. Patients' rating of pain management is reported. One hundred twenty-two and 62 patients were included during the pre- and post- QI periods, respectively. Post-QI, opioid prescribing decreased, and adjunct prescribing increased (31.1% vs. 72.6%; p < 0.001) at discharge. Interestingly, higher 24 h pre-discharge OME was associated with a higher OME prescribed at discharge (B = 1.255 [0.377 - 2.134]; p = 0.005). Of the 47 EGS patients who followed up in clinic post-ACS QI, 89.4% rated their pain management as excellent/good, 8.5% as fair, and 2.1% as poor. Implementation of a multifaceted approach to decrease opioid prescribing in the outpatient setting organically affected opioid prescribing habits at discharge for inpatients.

Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience

IntroductionAs the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. Materials and methodsWe performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. ResultsOver the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). ConclusionsAt our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.

Frailty in emergency general surgery: Low-risk procedures pose similar risk as high-risk procedures for frail patients

BackgroundThe association of frailty on postoperative outcomes after elective and emergency general surgery procedures has been widely studied. However, this association has not been examined in the geriatric population stratified by emergency general surgery procedural risk. MethodsA retrospective cohort study was performed using the 2012 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database. We identified geriatric patients (age ≥65 years) undergoing an emergency general surgery procedure within 48 hours of admission stratified by the procedural risk. Frailty was accessed using Modified 5-item Frailty Index, and the patients were divided into 4 groups Modified 5-item Frailty Index = 0, 1, 2, and ≥3. Multivariable logistic regression was used to assess the impact of increasing Modified 5-item Frailty Index score on postoperative complications, failure-to-rescue, and readmissions. ResultsIn the study, 16,911 low risk procedure emergency general surgery patients were grouped as (33.3%) Modified 5-item Frailty Index = 0, (45.1%) Modified 5-item Frailty Index = 1, (18.7%) Modified 5-item Frailty Index = 2, and (2.9%) Modified 5-item Frailty Index ≥3 respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 2.1 [1.3-3.5], Modified 5-item Frailty Index ≥ 3: 2.2 [1.2-4.2]), failure-to-rescue (Modified 5-item Frailty Index = 2: 2.3 [1.3-4.0], Modified 5-item Frailty Index ≥ 3: 2.3 [1.2-4.6]), readmission (Modified 5-item Frailty Index = 2: 1.4 [1.2-1.7], Modified 5-item Frailty Index ≥ 3: 1.5 [1.1-2.1]). In addition, 30,305 high-risk patients undergoing procedure emergency general surgery were grouped as (24.1%) Modified 5-item Frailty Index = 0, (44.9%) Modified 5-item Frailty Index = 1, (24.0%) Modified 5-item Frailty Index = 2, and (7.0%) Modified 5-item Frailty Index ≥3, respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 1.2 [1.2–1.3], Modified 5-item Frailty Index ≥3: 1.7 [1.5–2.0]), failure-to-rescue (Modified 5-item Frailty Index = 2: 1.3 [1.2–1.5], Modified 5-item Frailty Index ≥3: 1.5 [1.3–1.7]), readmission (Modified 5-item Frailty Index = 2: 1.3 [1.2–1.4], Modified 5-item Frailty Index ≥3: 1.6 [1.4–1.9]). ConclusionIncreasing levels of frailty in geriatric emergency general surgery patients are associated with higher levels of postoperative complications, failure-to-rescue, and readmission. Clinicians should consider frailty in assessing the risk of even low-risk surgeries in this population.

Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries

BackgroundQualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. MethodsThis retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. ResultsIn total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. ConclusionsOur study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.

Impact of Interfacility Patient Transport for Appendectomy on Patient Outcomes

<h3>Introduction</h3> Patients presenting to emergency departments with complaints requiring emergency general surgery (EGS) often require transport to tertiary care because fewer than 50% of hospitals have EGS services. The need for interfacility transport to tertiary care is associated with increased hospital length of stay (LOS) and morbidity among medical patients, however there is limited data available evaluating the cost and impact of transports among EGS patients. The purpose of this study was to analyze the costs, transport resource utilization, and outcomes of EGS patients transferred to tertiary care with acute appendicitis. <h3>Methods</h3> This was an IRB approved retrospective study of adult patients transferred from an in-network referral ED to a single tertiary care facility between 20 May 2015 & 30 September 2020 who were transferred with diagnosis of appendicitis. Data collected from the health system's electronic medical record (EMR) included patient demographics, emergency department and interfacility transport hemodynamics, diagnostic testing results, timeliness of referral and transport, transport level of care, social determinants of health, and patient charges. Data was analyzed with R version 1.0.2. Our Primary Outcome was the hospital length of stay and our secondary outcomes were time from initial presentation to incision, cost to patient, and transport resource allocation. <h3>Results</h3> A total of 480 adult patients were transferred for tertiary EGS care during the study period and were included in the final analysis. 89.4% of patients (n=429) received ambulance transport awhile 10.6% (n=51) were transported via private vehicle. All patients were discharged home alive. Critical Care Transport (CCT) teams transported 61.5% (n=295) of patients while Advanced Life Support (ALS) teams transported 26.0% (n=125). Although CCT teams were more likely than ALS teams to establish and maintain intravenous fluids (54.6% vs 37.6%, p=0.002) there was no difference in analgesia (36.9% vs 27.4% p=0.078), antiemetic (26.8% vs 20.0% p=0.178), or antibiotic (13.3% vs 6.4% p=0.062) administration between critical care and ALS providers. No life-saving interventions were provided by any transport team. Ambulance transport did not shorten hospital length of stay compared to transport via private vehicle (p=0.67). <h3>Conclusion</h3> In this single center study transport via ambulance did not reduce hospital length of stay compared to transport via private vehicle and there was no difference in the care provided between ALS and CCT teams.

The Influence of Social Determinants of Health on The Interfacility Transport of Patients for Appendicitis

<h3>Introduction</h3> Patients presenting to emergency departments with complaints requiring emergency general surgery (EGS) often require transport to tertiary care because fewer than 50% of hospitals have EGS services. The need for interfacility transport to tertiary care is associated with increased hospital length of stay (LOS) and morbidity among medical patients. Further Social Determinants of Health (SDOH) are known factors worsening patient outcomes. There is limited data available evaluating the presence and influence of SDOH among EGS patients transferred to tertiary care. The purpose of this study was to analyze the costs, transport resource utilization, and outcomes of EGS patients transferred to tertiary care with acute appendicitis. <h3>Methods</h3> This was an IRB approved retrospective study of adult patients transferred from an in-network referral ED to a single tertiary care facility between 20 May 2015 & 30 September 2020 who were transferred with diagnosis of appendicitis. Data collected from the health system's electronic medical record (EMR) included patient demographics, emergency department and interfacility transport hemodynamics, diagnostic testing results, timeliness of referral and transport, transport level of care, social determinants of health, and patient charges. Data was analyzed with R version 1.0.2. Our Primary Outcome was the hospital length of stay and our secondary outcomes were time from initial presentation to incision, cost to patient, and transport resource allocation. <h3>Results</h3> A total of 480 adult patients were transferred for tertiary EGS care during the study period and were included in the final analysis. 89.4% of patients (n=429) received ambulance transport awhile 10.6% (n=51) were transported via private vehicle. All patients were discharged home alive. SDOH were documented as present in 25.5% of patients transported via private vehicle and 30.8% of patients transferred via ambulance. The presence of SDOH did not length emergency department length of stay (p=0.12) or hospital length of stay (p=0.45). SDOH did not impact hospital length of stay when transport mode was also considered (p=0.447) <h3>Conclusion</h3> In this single center study, the presence of SDOH did not influence ED or hospital length of stay among patients transferred to tertiary care for appendectomy. Overall SDOH were poorly reported in the hospital and ambulance electronic medical record. Improved tracking of these social factors may alter the results of future research.

Predicting mortality and morbidity in emergency general surgery patients in a Jordanian Tertiary Medical Center: a retrospective validation study of the Emergency Surgery Score (ESS)

ObjectiveThe Emergency Surgery Score (ESS) is a predictive tool used to assess morbidity and mortality rates in patients undergoing emergent surgery. This study explores the ESS’s predictive ability and reliability...

Virtual Triage Practices in Emergency General Surgery Patients from Freestanding Emergency Departments: A 5-Year Analysis

INTRODUCTION: Freestanding Emergency Departments (FSEDs) have risen in popularity, reducing emergency department (ED) wait time and demand at overburdened hospitals. Although there has been limited evaluation into FSED utility in psychiatric populations, there are no data evaluating virtual triage disposition in surgical populations without physical examination by surgical team. We report our experience virtually triaging emergency general surgery (EGS) patients from an affiliated FSED to discharge, Level I trauma center (TC) or community hospital (CH). METHODS: EGS patients presenting to FSED with surgical consultation between 2016 and 2021 were analyzed. Outcomes included length of stay (LOS), surgical intervention, and 30-day mortality and readmission. Undertriage and overtriage rate was calculated and defined as: (1) discharge undertriage: discharge home with 30-day ED visit/readmission; (2) transfer undertriage: admission to CH requiring transfer to TC; and (3) overtriage: admissions <24 hours without operation. RESULTS: Of 1,105 patients, 167 (15%) were discharged home, 303 (27%) were transferred to TC, and 635 (58%) transferred to CH. Patients admitted to TC were older with higher Charlson Comorbidity Index scores and higher acuity pathology, but CH had higher operative rate and laparoscopy with shorter length of stay, operating room time, 30-day readmission, and mortality. Transfer undertriage was 0.9% (n = 6) with 1 due to disease acuity. Discharge undertriage was 12% (n = 20) due to worsening or stable pathology. Overtriage was 5.5% (n = 52) with most having a partial small-bowel obstruction or ambiguous diagnostic imaging necessitating observation. CONCLUSION: Virtual EGS triage at FSED to disposition, without an in-person examination, demonstrated both low undertriage and overtriage rate, reflecting appropriate triage practices.

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

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

Reconceptualizing high-quality emergency general surgery care: Non-mortality-based quality metrics enable meaningful and consistent assessment.

Ongoing efforts to promote quality-improvement in emergency general surgery (EGS) have made substantial strides but lack clear definitions of what constitutes "high-quality" EGS care. To address this concern, we developed a novel set of five non-mortality-based quality metrics broadly applicable to the care of all EGS patients and sought to discern whether (1) they can be used to identify groups of best-performing EGS hospitals, (2) results are similar for simple versus complex EGS severity in both adult (18-64 years) and older adult (≥65 years) populations, and (3) best performance is associated with differences in hospital-level factors. Patients hospitalized with 1-of-16 American Association for the Surgery of Trauma-defined EGS conditions were identified in the 2019 Nationwide Readmissions Database. They were stratified by age/severity into four cohorts: simple adults, complex adults, simple older adults, complex older adults. Within each cohort, risk-adjusted hierarchical models were used to calculate condition-specific risk-standardized quality metrics. K-means cluster analysis identified hospitals with similar performance, and multinomial regression identified predictors of resultant "best/average/worst" EGS care. A total of 1,130,496 admissions from 984 hospitals were included (40.6% simple adults, 13.5% complex adults, 39.5% simple older adults, and 6.4% complex older adults). Within each cohort, K-means cluster analysis identified three groups ("best/average/worst"). Cluster assignment was highly conserved with 95.3% of hospitals assigned to the same cluster in each cohort. It was associated with consistently best/average/worst performance across differences in outcomes (5×) and EGS conditions (16×). When examined for associations with hospital-level factors, best-performing hospitals were those with the largest EGS volume, greatest extent of patient frailty, and most complicated underlying patient case-mix. Use of non-mortality-based quality metrics appears to offer a needed promising means of evaluating high-quality EGS care. The results underscore the importance of accounting for outcomes applicable to all EGS patients when designing quality-improvement initiatives and suggest that, given the consistency of best-performing hospitals, natural EGS centers-of-excellence could exist. Prognostic and Epidemiological; Level III.

Resident-Led Effort Improves Adoption of Advance Care Planning among Emergency General Surgery Patients

INTRODUCTION: Advanced Care Planning (ACP) is underused in surgery, especially among older adults undergoing high-risk operations. For patients who may permanently or temporarily lose their ability to communicate preferences, pre-operative ACP and identification of a surrogate decision-maker is often the only mechanism to guide medical decision-making. METHODS: A resident-led, collaborative (faculty, advanced practice providers [APP], medical student, and nurse) quality improvement project including education (grand rounds, case-based conferences, didactic sessions), performance measurement and financial incentives, conducted on the Emergency General Surgery (EGS) service aimed to increase use of a tailored surgical template in the ACP tab in the electronic health record (EHR). 566 patients in the baseline period (2020-2021) were compared to 423 patients in the project period (2021-2022). Residents were surveyed about barriers to adoption. RESULTS: ACP compliance increased by 8.1% (10.1% to 18.2%) with a greater increase noted in patients age 65+ (20.3% vs 34.3%). Residents and APPs completed ACP, usually by integrating into patient admission workflow (52.1% within the first 24 hours of admission). For major cases, ACP compliance rates increased by 19.7% (18.9% to 38.6%). Residents surveyed (n = 19), all of whom had an ACP conversation all recognized the importance of ACP, noted barriers, including competing clinical duties (50%), patient or family hesitancy (30%), and language barriers (15%), (Table 1). CONCLUSION: A resident-APP partnership was effective at increasing ACP adoption on an EGS service. Further study is needed to identify approaches to facilitate ACP conversations in EGS patients with limited English proficiency.Table 1

Predicting Outcomes in Emergency General Surgery Patients Using Preoperative Model for End-Stage Liver Disease Score

INTRODUCTION: The Model for End-Stage Liver Disease (MELD) score is commonly used to predict liver-related mortality postoperatively in cirrhotic patients. Multiple studies have demonstrated its value in predicting adverse outcomes for patients without reported liver failure, all focused on outcomes for elective procedures. This study examined MELD scores and 30-day outcomes in adult patients undergoing emergent general surgery procedures. METHODS: This was a retrospective analysis of the American College of Surgeons NSQIP database from 2014 to 2018. General surgery patients more than 18 years old who underwent an emergent procedure were included. Patients who were missing preoperative laboratory values for sodium, international normalized ratio, bilirubin, and creatinine were excluded. A univariable and multivariable logistic regression with a nonlinear restricted cubic spline of the MELD score was performed. The models were controlled for age, sex, race, diabetes, smoking, COPD, congestive heart failure, and disseminated cancer. All analysis was done using R Version 4.1.2. RESULTS: A total of 123,104 patients were analyzed with 34.8% (n = 42,799) with MELD 10 to 19, 11.2% (n = 13,826) with MELD 20 to 29, and 1.3% (n = 1,575) with MELD 30 to 39. Of these patients, 7.8% (n = 9,640) died, 6.9% (n = 8,539) developed pneumonia, and 14.9% (n = 18,356) had a bleeding event within 30 days. The probability of mortality (chi-square [3df] = 7,170.7, p < 0.001), pneumonia (chi-square [3df] = 1,568.3, p < 0.001), and bleeding (chi-square [3df] = 6,436.5, p < 0.001) significantly correlate with MELD score (Fig. 1). The probability of mortality for a MELD 10 is 4.5%, for a MELD 20 is 15.6%, and for a MELD 30 is 36.0% for the average patient.Figure 1CONCLUSION: Across all variables, postoperative outcomes worsened in a nonlinear manner as MELD increased. MELD scores can be used in preoperative assessment of patients undergoing emergency general surgery.

Analyzing the Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery

INTRODUCTION: Many older patients with multiple comorbidities require emergency general surgery (EGS). Little is known about the impact of specific combinations of comorbidities (ie multimorbidity) on long-term outcomes for older EGS patients. METHODS: Medicare beneficiaries age 65 and older who presented to an acute care hospital and underwent EGS were identified using Medicare claims data (100% sample, 2015 to -2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions associated with increased risk of in-hospital mortality after general surgery) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using mixed-effects linear and logistic regression. RESULTS: Of 174,891 patients, 48.4% were identified as multimorbid. Multimorbid patients had higher rate of mortality and readmission through 180 days and higher rate of discharge to a rehabilitation/nursing facility or hospice (see Table). Compared with nonmultimorbid patients, multimorbid patients experienced longer index hospitalization (1.4 additional days, p < 0.001), higher cost through 180 days ($5,324 additional, p < 0.001), and greater than double the use of home oxygen (3.6% vs 1%, p < 0.001), walker (11.4% vs 4.2%, p < 0.001), wheelchair (1.9% vs 0.3%, p < 0.001), bedside commode (3.6% vs 1.1%, p < 0.001), and hospital bed (1.2% vs 0.2%, p < 0.001). Table. - Unadjusted and Adjusted Outcomes for Multimorbid and Nonmultimorbid Patients Outcomes metric Unadjusted proportion of multimorbid patients Unadjusted proportion of nonmultimorbid patients Adjusted odds ratio comparing multimorbid with nonmultimorbid patients p Value Died in hospital 5.8% 0.5% 3.75 <0.001 Died within 30 d 9.2% 1.2% 3.09 <0.001 Died within 90 d 13.5% 2.1% 2.7 <0.001 Died within 180 d 16.7% 3.1% 2.48 <0.001 Readmitted within 30 d 21.7% 10.9% 1.54 <0.001 Readmitted within 90 d 35.1% 13.2% 1.52 <0.001 Readmitted within 180 d 33.3% 15.3% 1.5 <0.001 Discharged to rehabilitation or nursing facility 29.7% 10.7% 1.72 <0.001 Discharged to hospice 2.2% 0.3% 2.6 <0.001 CONCLUSION: Among older patients, multimorbid patients experience worse outcomes after EGS than nonmultimorbid patients. Beyond survival, multimorbid patients experience greater loss of independence. This information is important for setting recovery expectations for high-risk patients to improve shared decision making.

Liver Function Tests after Laparoscopic Common Bile Duct Exploration Are Not Reliable

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) to manage choledocholithiasis at the time of cholecystectomy (LC+LCBDE) is gaining traction and requires examination of the role of postoperative laboratory data to guide clinical care. We examined postoperative liver function test (LFT) trends in the context of successful and failed LCBDE. METHODS: Retrospective review of all adult emergency general surgery (EGS) patients undergoing LCBDE over a 3-year period. Failed LC+LCBDE was defined as the subsequent need for endoscopic retrograde cholangiopancreatography (ERCP) for duct clearance. Postoperative LFTs from both successful and failed LCBDE attempts were analyzed. Postoperative laboratory values from all LC+LCBDE were classified as increased, decreased, or unchanged from preoperative. Procedure outcomes were analyzed. RESULTS: Sixty patients underwent LCBDE. Ten patients were excluded for not having preoperative laboratory tests or any postoperative laboratory tests. Thirty-three of the remaining 50 patients had 2 sets of postoperative laboratory tests. In patients who underwent successful LCBDE, there was no statistical difference (p > 0.05) between the preoperative and the 1st postoperative or 2nd postoperative laboratory tests regarding total bilirubin, aspartate/alanine aminotransferase, or alkaline phosphatase. For patients who had an unsuccessful LCBDE and required postoperative ERCP, this was also true. No patients with successful LCBDE with increased postoperative laboratory tests had complication. CONCLUSION: Despite the LCBDE outcome, postoperative laboratory tests do not provide reliable prognostication as would be expected in the given clinical context. Contrast flow into the duodenum and surgeon judgment are better indicators of duct clearance. It is safe to discharge patients without LFT after successful and uneventful LCBDE.

Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study.

Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare &amp; Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p &lt; 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p &lt; 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p &lt; 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p &lt; 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p &lt; 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p &lt; 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p &lt; 0.001), longer length of index hospitalization (1.33 additional in-patient days, p &lt; 0.001), and higher costs through 6 months ($5,162 additional, p &lt; 0.001). Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.

Measuring the Predictive Accuracy of Preoperative Clinical Frailty Instruments Applied to Electronic Health Data in Older Patients Having Emergency General Surgery: A Retrospective Cohort Study.

To compare predictive accuracy of frailty instruments operationalizable in electronic data for prognosticating outcomes among older adults undergoing emergency general surgery (EGS). Older patients undergoing EGS are at higher risk of perioperative morbidity and mortality. Preoperative frailty is a common and strong perioperative risk factor in this population. Despite this, existing barriers preclude routine preoperative frailty assessment. We conducted a retrospective cohort study of adults above 65 undergoing EGS from 2012 to 2018 using Institute for Clinical Evaluative Sciences (ICES) provincial healthcare data in Ontario, Canada. We compared 4 frailty instruments: Frailty Index (FI), Hospital Frailty Risk Score (HFRS), Risk Analysis Index-Administrative (RAI), ACG Frailty-defining diagnoses indicator (ACG). We compared predictive accuracy beyond baseline risk models (age, sex, American Society of Anesthesiologists' score, procedural risk). Predictive performance was measured using discrimination, calibration, explained variance, net reclassification index and Brier score (binary outcomes); using explained variance, root mean squared error and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes were 365-day mortality, nonhome discharge, days alive at home, length of stay, and 30-day and 365-day health systems cost. A total of 121,095 EGS patients met inclusion criteria. Of these, 11,422 (9.4%) experienced death 30 days postoperatively. Addition of FI, HFRS, and RAI to the baseline model led to improved discrimination, net reclassification index, and R2 ; RAI demonstrated the largest improvements. Adding 4 frailty instruments to typically assessed preoperative risk factors demonstrated strong predictive performance in accurately prognosticating perioperative outcomes. These findings can be considered in developing automated risk stratification systems among older EGS patients.