Emergency General Surgery Procedure Research Articles

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

IntroductionStudies 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. MethodsA 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. ResultsCompared 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]. ConclusionsProcedure-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.

Human Immunodeficiency Virus and Hepatitis C Virus-related Disparities in Undergoing Emergency General Surgical Procedures in the United States, 2016-2019.

To determine whether people living with human immunodeficiency virus (PLWHIV) and people living with hepatitis C virus (PLWHCV) experience inequities in receipt of emergency general surgery (EGS) care. PLWHIV and PLWHCV face discrimination in many domains; it is unknown whether this extends to the receipt of EGS care. Using data from the 2016 to 2019 National Inpatient Sample, we examined 507,458 nonelective admissions of adults with indications for one of the 7 highest-burden EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, or laparotomy). Using logistic regression, we evaluated the association between HIV/HCV status and the likelihood of undergoing one of these procedures, adjusting for demographic factors, comorbidities, and hospital characteristics. We also stratified analyses for the 7 procedures separately. After adjustment for covariates, PLWHIV had lower odds of undergoing an indicated EGS procedure [adjusted odds ratio (aOR): 0.81; 95% CI: 0.73-0.89], as did PLWHCV (aOR: 0.66; 95% CI: 0.63-0.70). PLWHIV had reduced odds of undergoing cholecystectomy (aOR: 0.68; 95% CI: 0.58-0.80). PLWHCV had lower odds of undergoing cholecystectomy (aOR: 0.57; 95% CI: 0.53-0.62) or appendectomy (aOR: 0.76; 95% CI: 0.59-0.98). PLWHIV and PLWHCV are less likely than otherwise similar patients to undergo EGS procedures. Further efforts are warranted to ensure equitable access to EGS care for PLWHIV and PLWHCV.

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.

Major adverse cardiovascular events and all-cause mortality after emergency general surgery among kidney failure patients.

Emergency general surgery (EGS) is associated with increased mortality, with kidney failure a contributing risk, but comparative outcomes between patients with kidney failure and the general population are lacking. In this retrospective population-cohort study, data were analysed for all EGS procedures performed in England between 1 April 2004 and 31 March 2019. EGS was defined as partial colectomy, small bowel resection, cholecystectomy, appendicectomy, lysis of peritoneal adhesions, surgery for peptic ulcer, or laparotomy. The main outcome measure was major adverse cardiovascular events (MACEs) and all-cause mortality after surgery. From 691 064 procedures, 0.16 per cent (n = 1097) and 0.23 per cent (n = 1567) were performed on kidney transplant and dialysis recipients respectively. Laparotomy was the most frequent EGS procedure for kidney transplant (46 per cent of procedures, n = 507) and dialysis (45 per cent of procedures, n = 704) recipients, with the highest 30-day and 1-year mortality. In logistic regression analysis, both kidney failure cohorts had higher risk for experiencing MACEs in the postoperative interval after emergency laparotomy; within 3 months (dialysis; OR 2.44 (95 per cent c.i. 2.08 to 2.87), P &lt; 0.001 and transplant; OR 2.05 (95 per cent c.i. 1.57 to 2.68), P &lt; 0.001) and within 1 year (dialysis; OR 2.39 (95 per cent c.i. 2.06 to 2.77), P &lt; 0.001 and transplant; OR 2.21 (95 per cent c.i. 1.76 to 2.77), P &lt; 0.001); however, in a propensity-score-matched cohort, increased risk for MACEs was observed among dialysis patients after emergency laparotomy (HR 2.10 (95 per cent c.i. 1.82 to 2.43), P &lt; 0.001) but not kidney transplant recipients (HR 1.17 (95 per cent c.i. 0.97 to 1.41), P = 0.096). Mortality after emergency surgery is higher for patients with kidney failure and dialysis is worse than kidney transplantation, with cardiovascular deaths more common than the general population.

BMI and VTE Risk in Emergency General Surgery, Does Size Matter? : An ACS-NSQIP Database Analysis.

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. Emergency general surgery (EGS) patients comprise 7% of hospital admissions in America with a reported rate of VTE of 2.5%. Of these, >69% required hospital readmission, making VTE the second most common cause for readmission after infection in EGS patients. We hypothesize a correlation between body mass index (BMI) and VTE in EGS patients. The American College of Surgeons National Surgery Quality Improvement Database (NSQIP) was queried from January 2015 to December 2016. 83 272 patients met inclusion criteria: age ≥18 and underwent an EGS procedure. Patients were stratified by BMI. Descriptive statistics were used for demographic and numerical data. Categorical comparisons between covariates were completed using the chi-square test. Continuous variables were compared using Student's t-test, Mann Whitney U-test, or Kruskal-Wallis H test. 83 272 patients met the inclusion criteria. 1358 patients developed VTE (903 deep vein thrombosis (DVT) only, 335 pulmonary embolism (PE) only, and 120 with DVT and PE). Morbidly obese patients were 1.7 times more likely to be diagnosed with a PE compared with normal BMI (P = .004). Increased BMI was associated with the co-diagnosis of PE and DVT (P = .027). Patients with BMI <18.5 were 1.4 times more likely to experience a VTE compared with normal BMI (P = .018). Patients with a VTE were 3.2 times more likely to die (P < .001) and less likely to be discharged home (P < .001). Our study found that obese and underweight EGS patients had an increased incidence of VTE. Risk recognition and chemoprophylaxis may improve outcomes in this population.

Barriers to improving health care value in emergency general surgery: A nationwide analysis.

There is a growing need to improve the quality of care while decreasing health care costs in emergency general surgery (EGS). Health care value includes costs and quality and is a targeted metric by improvement programs. The aim of our study was to evaluate the trend of health care value in EGS over time and to identify barriers to high-value surgical care. The (2012-2015) National Readmission Database was queried for patients 18 years or older who underwent an EGS procedure (according to the American Association for the Surgery of Trauma definition). Health care value (V = quality metrics/cost) was calculated from the rates of freedom from readmission, major complications, reoperation, and failure to rescue (FTR) indexed over inflation-adjusted hospital costs. Outcomes were the trends in the quality metrics: 6-month readmission, major complications, reoperation, FTR, hospital costs, and health care value over the study period. Multivariable linear regression was performed to determine the predictors of lower health care value. We identified 887,013 patients who underwent EGS. Mean ± SD age was 51 ± 20 years, and 53% were male. The rates of 6-month readmission, major complications, reoperation, and FTR increased significantly over the study period. The median hospital costs also increased over the study period (2012, US $9,600 to 2015, US $13,000; p < 0.01). However, the health care value has decreased over the study period (2012, 0.35; 2013, 0.30; 2014, 0.28; 2015, 0.25; p < 0.01). Predictors of decreased health care value in EGS are age 65 years or older (β = -0.568 [-0.689 to -0.418], more than three comorbidities (β = -0.292 [-0.359 to -0.21]), readmission to a different hospital (β = -0.755 [-0.914 to -0.558]), admission to low volume centers (β = -0.927 [-1.126 to -0.682]), lack of rehabilitation (β = -0.004 [-0.005 to -0.003]), and admission on a weekend (β = -0.318 [-0.366 to -0.254]). Health care value in EGS appears to be declining over time. Some of the factors leading to decreased health care value in EGS are potentially modifiable. Health care value could potentially be improved by reducing fragmentation of care and promoting regionalization. Economic, level IV.

No news is good news? Three-year postdischarge mortality of octogenarian and nonagenarian patients following emergency general surgery.

Outcome data on the very elderly patients undergoing emergency general surgery (EGS) are sparse. We sought to examine short- and long-term mortality in the 80 plus years population following EGS. Using our institutional 2008-2018 EGS Database, all the 80 plus years patients undergoing EGS were identified. The data were linked to the Social Security Death Index to determine cumulative mortality rates up to 3 years after discharge. Univariate and multivariable logistic regression analyses were used to determine predictors of in-hospital and 1-year cumulative mortality. A total of 385 patients were included with a mean age of 84 years; 54% were female. The two most common comorbidities were hypertension (76.1%) and cardiovascular disease (40.5%). The most common procedures performed were colectomy (20.0%), small bowel resection (18.2%), and exploratory laparotomy for other procedures (15.3%; e.g., internal hernia, perforated peptic ulcer). The overall in-hospital mortality was 18.7%. Cumulative mortality rates at 1, 2, and 3 years after discharge were 34.3%, 40.5%, and 43.4%, respectively. The EGS procedure associated with the highest 1-year mortality was colectomy (49.4%). Although hypertension, renal failure, hypoalbuminemia, hyperbilirubinemia, and elevated liver enzymes predicted in-hospital mortality, the only independent predictors of cumulative 1-year mortality were hypoalbuminemia (odds ratio, 2.17; 95% confidence interval, 1.10-4.27; p = 0.025) and elevated serum glutamic pyruvic transaminase (SGOT) level (odds ratio, 2.56; 95% confidence interval, 1.09-4.70; p = 0.029) at initial presentation. Patients with both factors had a cumulative 1-year mortality rate of 75.0%. More than half of the very elderly patients undergoing major EGS were still alive at 3 years postdischarge. The combination of hypoalbuminemia and elevated liver enzymes predicted the highest 1-year mortality. Such information can prove useful for patient and family counseling preoperatively. Prognostic, Level III.

Care Discontinuity in Emergency General Surgery: Does Hospital Quality Matter?

Changes in care providers and hospitals after emergency general surgery (EGS) (care discontinuity) are associated with increased morbidity and mortality. The cause of these worse outcomes is unknown. Our goal was to determine if hospital quality is associated with mortality after readmissions independent of continuity in care. This was a retrospective analysis of Medicare inpatient claims (2007 to 2015). All inpatients older than 65 years of age who underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally, were included. Care discontinuity was defined as readmission within 30 days to a nonindex hospital. Hospital quality was determined by hospital-level, risk-adjusted mortality rates by EGS procedure and categorized into high quality (HQ) and low quality (LQ). The primary outcome was overall mortality. Multivariate logistic regression analysis was used to determine the association of discontinuity and mortality. There were 882,929 EGS patients, 87,232 of whom were readmitted within 30 days of discharge. Care discontinuity was independently associated with mortality (odds ratio [OR] 1.23; 95% CI 1.17 to 1.29). When readmitted patients were stratified by quality of index and readmitting hospital, mortality was associated with the quality of both the index hospital and the readmitting hospital. The highest mortality rate was observed in patients with index admission at low-quality hospitals and readmission to a different low-quality hospital. Both care discontinuity and hospital quality are independently associated with mortality in EGS patients. These data support maintaining continuity of care, even at low performing hospitals.

Acute kidney injury is independently associated with mortality and resource use after emergency general surgery operations

IntroductionThe incidence of severe perioperative renal dysfunction in high-acuity patients has not been well-explored at the national level. The present study aimed to evaluate the trends in the incidence of perioperative acute kidney injury and renal replacement therapy as well as associated mortality among patients undergoing an emergency general surgery operation. MethodsThis was a retrospective cohort study using the National Inpatient Sample to identify all adult patients (>18 y) without chronic kidney disease who underwent an emergency general surgery procedure from 2008 to 2016. The study cohort was stratified based on presence of acute kidney injury and need for renal replacement therapy postoperatively. A multivariable logistic regression model was developed to predict the odds of mortality and composite morbidity. Nonparametric trend analyses of acute kidney injury and renal replacement therapy incidence and associated mortality were performed. ResultsOf an estimated 5,862,657 patients who underwent an emergency general surgery procedure during the study period, 7.4% patients developed an acute kidney injury and 0.48% patients required renal replacement therapy. Overall, the incidence of acute kidney injury (5.3%–19.4%) and renal replacement therapy (0.43%–0.93%) increased (P < .0001) over the study period. Even without need for renal replacement therapy, acute kidney injury was associated with greater odds of mortality and composite morbidity (adjusted odds ratio 5.2, 95% confidence interval [CI] 5.1–5.3) and mortality (adjusted odds ratio = 2.20, 95% CI 2.3–2.4), as well as greater costs of hospitalization and duration of stay. ConclusionIn this national study, we found that the incidence of acute kidney injury and renal replacement therapy after an emergency general surgery operation has increased. Both acute renal failure and hemodialysis were associated with much greater odds of morbidity and mortality. The apparent increase in the rate of acute kidney injury and renal replacement therapy warrant further investigation of mechanisms for monitoring and limiting the impact of organ malperfusion associated with emergency general surgery operations.

Prolonged operating room time in emergency general surgery is associated with venous thromboembolic complications

BackgroundWe evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS). MethodsWe reviewed six common EGS procedures in the 2013–2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions. ResultsOf 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5–16] for DVTs and 8 days [5–16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12–2.21]) and PE (OR:1.25 [1.11–2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis. ConclusionProlonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation.

Association of Medicaid Expansion Policy with Outcomes in Homeless Patients Requiring Emergency General Surgery.

Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS. We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare. A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388-52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79-2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7-1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08-4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4-0.8; p = 0.01). Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.

Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes.

Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes. We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters. We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes. Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients. Prognostic and epidemiological, level IV.

Effect of time to operation on outcomes in adults who underwent emergency general surgery procedure

BackgroundPatients who undergo an emergency procedure have an increase in postoperative morbidity and mortality. Emergency procedures constitute 14.2% of all general surgery procedures and account for 53.5% of deaths. Among this population, time to surgery from arrival to the emergency department (ED) has not been evaluated as an independent risk factor for morbidity and mortality. Material and methodsPatients who underwent an emergency general surgery procedure from 2013 to 2015 were identified using a local American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Outcomes of interest included 30-d mortality, all morbidity, and severe morbidity. Multivariate analyses were conducted using a logistic regression model using clinically relevant covariates to determine predictors of the outcome measures. ResultsA total of 974 patients were included in the final analysis. The prolonged median time from ED presentation to OR was predictive of all morbidity (14.3 h versus 13.3 h, P = 0.009) and severe morbidity (13.3 h versus 14.4 h, P = 0.063) on univariate analysis. Time from ED presentation to OR was not predictive of mortality (13.5 h versus 13.6 h, P = 0.474). Multivariate analysis demonstrated an adjusted increased odd of morbidity of 2.3 (95% CI: 1.01-5.24) for priority level A cases within the fourth quartile compared to that of the first quartile of time (P = 0.048). ConclusionsThis study corroborates with known data that morbidity and mortality increases in patients who are older, have multiple comorbidities, and higher ASA class. Furthermore, the time from ED arrival to the OR is associated with an overall increase in morbidity.

POST-OP: A Strategy to Improve Clinical Documentation in the Early Postoperative Period

To construct and pilot an educational tool to improve the quality of postoperative documentation at Mayo University Hospital. Retrospective data were collected from 100 consecutive patients treated surgically during October to November 2016. The first written ward based note following surgery was analyzed against RCS quality standards outlined in "Good Surgical Practice." An educational tool was then constructed to improve postoperative documentation. The mnemonic created was POST-OP-physiotherapy/mobilization, operative diagnosis, sepsis, thromboprophylaxis, oral intake/fluid balance, and pain. A second audit cycle involving 103 patients was carried out prospectively in March 2017. Mayo University Hospital, a 330 bed teaching hospital affiliated with the National University of Ireland, Galway. All patients who had undergone either an elective or an emergency general surgery procedure over two 5-week periods. Comparing the 2 study periods, significant improvements in the quality of postoperative surgical documentation was observed. All standards improved including patient identification (17.8% vs 78.1%, p < 0.001) and name of note maker (54.7% vs 86.2%, p < 0.001). There was also improvement in the documentation of antibiotic use (23.8% vs 75.8%, p > 0.001), thromboprophylaxis (7.1% vs 75.8%, p < 0.001), analgesia (36.9% vs 74.7%, p < 0.001), operative diagnosis (66.6% vs 91.9%, p < 0.001), and mobilization (23.6% vs 78.1%, p < 0.001) following the introduction of the POST-OP tool. The design and introduction of the POST-OP education tool helped to significantly improve documentation and educate surgical residents on the essential components of postoperative care. The above data suggest that this effective mnemonic can improve the quality of postoperative documentation for surgical patients.

Malnutrition at Intensive Care Unit Admission Predicts Mortality in Emergency General Surgery Patients

Emergency general surgery (EGS) patients are at an increased risk for morbidity and mortality compared with non-EGS patients. Limited information exists regarding the contribution of malnutrition to the outcome of critically ill patients who undergo EGS. We hypothesized that malnutrition would be associated with increased risk of 90-day all-cause mortality following intensive care unit (ICU) admission in EGS patients. We performed an observational study of patients treated in medical and surgical ICUs at a single institution in Boston. We included patients who underwent an EGS procedure and received critical care between 2005 and 2011. The exposure of interest, malnutrition, was determined by a registered dietitian's formal assessment within 48 hours of ICU admission. The primary outcome was all-cause 90-day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. The cohort consisted of 1361 patients. Sixty percent had nonspecific malnutrition, 8% had protein-energy malnutrition, and 32% were without malnutrition. The 30-day readmission rate was 18.9%. Mortality in-hospital and at 90 days was 10.1% and 17.9%, respectively. Patients with nonspecific malnutrition had a 1.5-fold increased odds of 90-day mortality (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.09-5.04; P = .009) and patients with protein-energy malnutrition had a 3.1-fold increased odds of 90-day mortality (adjusted OR, 3.06; 95% CI, 1.89-4.92; P < .001) compared with patients without malnutrition. In critically ill patients who undergo EGS, malnutrition at ICU admission is predictive of adverse outcomes. In survivors of hospitalization, malnutrition at ICU admission is associated with increases in readmission and mortality.

Prevalence and Predictors of Opioid Prescription at Discharge after Emergency General Surgery

The prevalence of moderate-to-severe pain after hospital discharge in patients after general surgery procedures is high, and opioids are a predominant analgesic agent used to treat pain in this population. Post-discharge pain and prescribing patterns are unknown in the emergency general surgery (EGS) population. Our aim was to study the proportion and predictors of opioid prescription in EGS patients at discharge. The 2007 to 2013 TRICARE insurance database was queried for opioid-naive patients 18-64 years, who underwent an EGS procedure. The outcome was prescription of opioid analgesics at discharge. Data collection included patient demographics and clinical characteristics. Logistic regression models were used to determine the predictors of opioid prescription. A total of 26,647 patients met our inclusion criteria where 3,476 (13%) received an opioid prescription at discharge. In multivariate analysis, male sex (odds ratio [OR]: 2.12, 95% CI: 1.78–2.51) and rank (enlisted-seniors vs officers, OR: 1.23, 95% CI: 1.04–1.45) were associated with higher likelihood of opioid prescription. Depression diagnosis (OR: 0.38, CI: 0.26–0.54), anxiety diagnosis (OR: 0.26, CI: 0.17–0.38) and pre-existing comorbidities (Charlson Comorbidity Index ≥ 1, OR: 0.61, CI: 0.47–0.79) were associated with decreased likelihood of opioid prescription. Age and race were not significant predictors of opioid prescription. The rate of opioid prescription in EGS patients was low and may be due to the use of non-narcotic adjuncts for pain management. Further studies are needed to understand and optimize pain management strategies for this group of high-risk patients undergoing complex surgical procedures.

Tu1728 - Effect of Time to Operation on Outcomes in Adults who Underwent an Emergency General Surgery Procedure: A Local ACS-NSQIP Retrospective Analysis

Tu1728 - Effect of Time to Operation on Outcomes in Adults who Underwent an Emergency General Surgery Procedure: A Local ACS-NSQIP Retrospective Analysis

Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients.

Emergency general surgery (EGS) patients have a disproportionate burden of death and complications. Chronic liver disease (CLD) increases the risk of complications following elective surgery. For EGS patients with CLD, long-term outcomes are unknown and risk stratification models do not reflect severity of CLD. To determine whether the Model for End-Stage Liver Disease (MELD) score is associated with increased risk of 90-day mortality following intensive care unit (ICU) admission in EGS patients. We performed a retrospective cohort study of patients with CLD who underwent an EGS procedure based on International Classification of Diseases, Ninth Revision (ICD-9) procedure codes and were admitted to a medical or surgical ICU within 48 hours of surgery between January 1, 1998, and September 20, 2012, at 2 academic medical centers. Chronic liver disease was identified using ICD-9 codes. Multivariable logistic regression was performed. The analysis was conducted from July 1, 2015, to January 1, 2016. The primary outcome was all-cause 90-day mortality. A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98). In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.

Which Complications Matter Most? Prioritizing Quality Improvement in Emergency General Surgery

Because preoperative risk factor modification is generally not possible in the emergency setting, complication prevention represents an important focus for quality improvement in emergency general surgery (EGS). The objective of our study was to determine the overall impact that specific postoperative complications have in this patient population. Our study sample consisted of patients from the 2012-2013 ACS-NSQIP database who underwent an EGS procedure. We used population attributable fractions (PAFs) to estimate the overall impact that each of 8 specific complications had on 30-day physiologic and resource use outcomes in our study population. The PAF represents the percentage reduction in a given outcome that would be anticipated if a complication were able to be completely prevented in our study population. Both unadjusted and risk-adjusted PAFs were calculated. There were 79,183 patients included for analysis. The most common complications in these patients were bleeding (6.2%), incisional surgical site infection (SSI) (3.4%), pneumonia (2.7%), and organ/space SSI (2.6%). Bleeding was the complication with the greatest overall impact on mortality and end-organ dysfunction, demonstrating an adjusted PAFof 10.7% (95% CI 8.2%,13.1%, p < 0.001) and 15.9% (95% CI 13.9%, 16.7%, p<0.001) for these respective outcomes. The only other complication with a sizeable impact on these outcomes was pneumonia (adjusted PAF of 7.9% for mortality and 13.2% for pneumonia). In contrast, complications such as urinary tract infection, venous thromboembolism, myocardial infarction, and incisional SSI had negligible impacts on these outcomes. Our study provides a framework for the development of high-value quality initiatives inEGS.

Factors affecting morbidity in emergency general surgery

Background Emergency status adversely affects surgical outcomes. Predictors of increased morbidity of emergency general surgery are unknown. We determined predictors of postoperative complications of emergency general surgery. Methods We conducted a retrospective study of Brigham and Women's Hospital American College of Surgeons National Surgical Quality Improvement Program patients who had an emergency general surgery procedure from January 1, 2007, to December 31, 2009. Additional non–American College of Surgeons National Surgical Quality Improvement Program variables were collected. Our primary outcome was postoperative complications within 30 days. Results Of 819 cases, 24.7% had 1 or more complications, with 8.9% mortality within 30 days. Common complications were respiratory (47%) and wound occurrences (18%). Age, sex, blood glucose level, creatinine level, albumin level, surgery duration, and smoking were independent predictors of morbidity. Conclusions Emergency general surgery patients with postoperative complications are likely to be older, male, smokers, have increased blood glucose and creatinine levels, lower albumin levels, and longer surgical times. Fluid resuscitation and experienced surgical teams are putative targets to improve outcomes.