Emergency General Surgery Procedures Research Articles

WP4.5 - Changes in Social Care Post Major Emergency General Surgery Procedures

Abstract Introduction Emergency General Surgery (EGS) is a major part of the provision of healthcare and patients undergoing EGS are at elevated risk of morbidity and mortality. The aim of this study is to determine factors contributing to patients losing their independence and being discharged to residential and nursing homes having previously lived in their own residences. Methods Data from patients in the NELA database (2014-2022) was analysed, considering demographics, ASA score, admission and discharge dates, presenting pathology, operation type, and discharge destination. Comparative analyses segmented patients based on post-discharge EGS destinations. Multivariable logistic regression identified factors linked to residential/nursing home placement post-discharge. Significance was set at p<0.05. Results Data from all patients in the NELA database (n=1,611) was analysed. Nearly one in ten patients over the age of 70 never returned home. Patients requiring additional support were on average 8.6 years older (p=0.008). Over the age of 80 years, the need for extra social support increased substantially with each increasing year in age and those over the age of 85 years old were more than twice as likely to require extra support than 80-year-olds (p<0.001). Patients who died were 11.4 years older compared to those discharged without additional support (p<0.001). Conclusion A significant proportion of patients, particularly the elderly, do not return to their usual place of residence and require a higher level of care post-emergency surgery. These important social factors need to be considered before operating as they may have significant quality of life and economic implications.

Patient-Reported Outcomes and Post-Traumatic Stress Disorder Symptoms in Emergency General Surgery

IntroductionPatient-reported outcomes (PRO) are increasingly recognized as a measure of surgical quality and long-term outcomes. There are few PRO data for patients undergoing emergency general surgery (EGS) procedures. Sudden illness and injury are associated with worse health-related quality of life, symptoms of depression, post-traumatic stress. This study aimed to evaluate PRO and post-traumatic stress disorder (PTSD) symptoms in an EGS population. MethodsPatients who underwent an EGS operation and had quality improvement data available from Jan 2020 to Jan 2021 were eligible for inclusion. Participants completed a survey of demographics, socio-economic status, PROMIS PRO measures for general life satisfaction (GLS), general self-efficacy (GSE), and physical function (PF), and the PCL-5 PTSD symptom screening tool. ResultsOne hundred forty-one patients were eligible for inclusion, 40 (28%) completed the study. Mean PRO scores were 52.5 ± 9.3 for GLS, 48.6 ± 8.0 for GSE, and 48.7 ± 9.6 for PF. 12.5% of patients had a low or very low GLS and GSE score, while 32.5% had mild, moderate, or severe PF scores. Seven patients (17.5%) scored >31 on PCL-5 indicating a positive PTSD screen. Regression analysis found American society of anesthesiology score, emergency case, and lower income associated with lower GLS scores. Age, body mass index, and lower income were associated with lower PF scores. ConclusionsWe found that following EGS most patients have average PRO. This limited study did also identify that there are patients potentially at risk for worse functional and mental health outcomes. We plan to use this data to prospectively evaluate the role that EGS plays in these outcomes and how they can be improved on.

Does delayed operation increase morbidity and mortality? An analysis of emergency general surgery procedures.

Early operation is assumed to improve outcomes after emergency general surgery (EGS) procedures; however, few data exist to inform this opinion. We aimed to (1) characterize time-to-operation patterns among EGS procedures and (2) test the association between timing and patient outcomes. We hypothesize that patients receiving later operations are at greater risk for mortality and morbidity. We performed a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program data for adults aged 18 to 89 years who underwent nonelective intra-abdominal operations (appendectomy, cholecystectomy, small bowel resection, lysis of adhesions, and colectomy) from 2015 to 2020. The primary outcome was 30-day postoperative mortality. Secondary outcomes were serious morbidity and all morbidity. Admission-to-operation timing was calculated and classified as early (≤48 hours) or late (>48 hours). A multivariable logistic regression model adjusted risk estimates for age, comorbidities, frailty (Modified Frailty Index, 5-item score), and other confounders. Of 269,959 patients (mean age, 47.0 years; 48.0% male, 61.6% White), 88.7% underwent early operation, ranging from 70.36% (lysis of adhesions) to 98.67% (appendectomy). Unadjusted 30-day mortality was higher for late versus early operation (6.73% vs. 1.96%; p < 0.0001). After risk adjustment, late operation significantly increased risk for 30-day mortality (odds ratio [OR], 1.545; 95% confidence interval [CI], 1.451-1.644), serious morbidity (OR, 1.464; 95% CI, 1.416-1.514), and all morbidity (OR, 1.468; 95% CI, 1.417-1.520). This mortality risk persisted for all EGS procedures; risk of serious and any morbidity persisted for all procedures except cholecystectomy. Late operation significantly increased risk for 30-day mortality, serious morbidity, and all morbidity across a variety of EGS procedures. We believe that these findings will inform decisions regarding timing of EGS operations and allocation of surgical resources. Therapeutic/Care Management; Level III.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures

BackgroundDespite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. MethodsWe performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. ResultsAmong our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. ConclusionSevere intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

Changes in social care after major emergency general surgery procedures

IntroductionEmergency General Surgery (EGS) is a major part of the provision of healthcare and patients undergoing EGS are at elevated risk of morbidity and mortality. The aim of this study is to determine factors contributing to patients losing their independence and being discharged to residential and nursing homes having previously lived in their own residences. MethodsOur local data uploaded to the National Emergency Laparotomy Audit (NELA) database (2014-2022) was analysed. This national database encompasses all major emergency general surgery cases undertaken in the United Kingdom. The variables considered were patient demographics, ASA score, admission and discharge dates, presenting pathology, operation type, and discharge destination. Comparative analyses segmented patients based on post-discharge EGS destinations. Multivariable logistic regression identified factors linked to residential/nursing home placement post-discharge. Significance was set at p<0.05. ResultsData from all patients in the NELA database (n=1,611) was analysed. Nearly one in ten patients over the age of 70 never returned home. Patients requiring additional support were on average 8.6 years older (p=0.008). Over the age of 80 years, the need for extra social support increased substantially with each increasing year in age and those over the age of 85 years old were more than twice as likely to require extra support than 80-year-olds (p<0.001). Patients who died were 11.4 years older compared to those discharged without additional support (p<0.001). ConclusionA significant proportion of patients, particularly the elderly, do not return to their usual place of residence and require a higher level of care post-emergency surgery. These important social factors need to be considered before operating as they may have significant quality of life and economic implications.

Patient reported outcomes of emergency general surgery procedures

BackgroundEmergency general surgery (EGS) involves care of a patient's often previously unknown disease in the setting of an unplanned interaction with the healthcare system. This leads to challenges collecting and interpreting patient reported outcome measures (PROMs). MethodsWe performed a qualitative and mixed methods study using semi-structured interviews during the index hospitalization and at 6–12 months to capture peri-operative patient experiences. We compared interview findings to clinical characteristics. ResultsAmong 30 patients, two-thirds reported feeling no choice but to pursue emergency surgery with many reporting exclusion from decision-making. Females reported these themes more commonly. Patients with minor complications less frequently reported trust in their team and discussed communication issues and delays in care (all p ​< ​0.05). Patients with major complications more frequently reported confidence in their team and gratefulness, but also communication limitations (all p ​< ​0.05). Patients not admitted to the ICU more frequently discussed good communication and expeditious treatment. ConclusionsPROMs developed for EGS patients should consider patient outcomes and reflections that they felt excluded from decision-making. Severity of complications may also differentially impact PROMs.

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.

Work relative value units undervalue the clinical effort associated with teaching cases: An ACS-NSQIP analysis

PurposeWork-relative-value-units (wRVUs) are a core metric of faculty effort but do not account for the additional work associated with intraoperative teaching. This study introduces and assesses an indexed effort, wRVU per minute (wRVU index). We hypothesize that there is a significant decrease in the calculated wRVU index among teaching cases. MethodsWe queried the ACS-NSQIP database for 7 core Emergency General Surgery procedures and records were stratified into teaching vs non-teaching, and emergent vs non-emergent procedures. We utilized multivariable generalized linear models to determine factors associated with increased operative time and decreased wRVU index. ResultsData were available for 953,967 cases from 2005 to 2010. For all cases, teaching vs non-teaching, the median wRVU index was 0.16 vs 0.21 (p ​< ​0.001). There was a positive association between teaching cases and decreased wRVU index for all cases. ConclusionThe wRVU index was 24% lower for teaching cases when compared to non-teaching cases despite controlling for patient-specific factors. This finding highlights the need for further evaluation of the current wRVU framework.

Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures

Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown. To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults. This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race. Primary care utilization in the year prior to presentation for an EGS operation. In-hospital, 30-day, 60-day, 90-day, and 180-day mortality. A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different. In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.

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.

Emergency General Surgery Procedures in Older Adults: Where You Live Matters!

Neighborhood location and its built environment are important social determinants of health that impact health outcomes. Older adults (OAs) represent the fastest growing population in the United States with many requiring emergency general surgery procedures (EGSPs). The aim of this study was to evaluate whether neighborhood location, represented by zip code, influences mortality and disposition in OAs undergoing EGSPs in Maryland. A retrospective review was undertaken of hospital encounters in the Maryland Health Services Cost Review Commission from 2014 to 2018 of OAs undergoing EGSPs. Older adults residing in the 50 most affluent (MANs) and 50 least affluent (LANs) neighborhoods based on zip codes were compared. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index, complications, mortality, and discharge to a higher level of care. Of the 8661 OAs analyzed, 2362 (27.3%) resided in MANs and 6299 (72.7%) in LANs. Older adults in LANs were more likely to undergo EGSPs, had higher APR-SOI and APR-ROM, and experienced more complications, discharge to higher level of care, and mortality. Living in LANs was independently associated with discharge to higher level of care (OR 1.56, 95% CI: 1.38-1.77, P < .001) and increased mortality (OR 1.35, 95% CI: 1.07-1.71, P = .01). Mortality and quality of life in OAs undergoing EGSPs are dependent on environmental factors likely determined by neighborhood location. These factors need to be defined and incorporated in predictive models of outcomes. Public health opportunities to improve outcomes for those who are socially disadvantaged are necessary.

Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries.

Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery. This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation). Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p < 0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p < 0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes. National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.

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.

EGS P15 Role of electronic consent in emergency surgery – A QIP in a high volume surgical emergency unit at a tertiary hospital

Abstract Background The Royal College of Surgeons of England discusses the significance of maintaining a written record of consent in addition to completing the consent form under section 4.10 of the supported decision-making guide to good practice - “any written information given to the patient should also be recorded and copies should be included in the patient's notes”. Studies show high error rates (27–50%) with handwritten consent forms due to poor legibility, incomplete/ inaccurate information, increased variability, and risk of misplacement. The consequences of these errors can lead to poor patient experience as well as unfavourable outcomes at the operational and institutional levels. Missing or incomplete consent is also the most common reason for first case delay (average 1–75mins). This prompted the QIP and generation of a standard template for the common emergency general surgery procedures in a high-volume Surgical Emergency Unit (SEU) at the John Radcliffe Hospital. Methods Procedure-specific Electronic Surgical Consent (eSConsent) template for common emergency general surgery operations was added to the online database to easily be added to the electronic patient record. The format, as outlined below, was designed to allow even junior surgical trainees to adapt and perform the consent process early on in their placement- Results The consent for all the emergency general surgery cases in a given week was reviewed and the compliance to maintaining eSConsent was audited. The first cycle between 20th-26th September 2021 showed compliance of only 18% (9 out of 49 operations). After discussing the audit findings with the members of the surgical team involved in the consenting process in the local meeting and implementing eSConsent, the compliance increased to 83.7% (36 of 43 cases) in the following week, 78% (33 of 43 cases) between 12th-18th November 2021 and 73% (28/38 operations) in the beginning of March 2022. Conclusions A consent form is a medicolegal document. Health care systems have taken advantage of technology to facilitate accuracy and robust monitoring. The emergency surgical consent process can benefit from this to avoid delays, errors and litigation. This transition is justifiable from our results and easily translated to practice particularly by using simple technology demonstrated in our QIP. Challenges including trainee changeover and new recruitments will expectedly affect the compliance of eSConsent but a proper induction to ensure adequate staff education will help overcome this. Weekly data capture has been adopted in our department as a surveillance protocol to ensure adherence and to standardize our practice.

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.

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.

Prevalence of Advanced Care Planning in Emergency General Surgery: Do We Know Our Patient’s Goals?

INTRODUCTION: Advanced care planning (ACP) promotes the delivery of goal-concordant, patient-centered surgical care. There is opportunity to increase ACP adoption in surgery. We hypothesized that, on the emergency general surgery (EGS) service, most patients were not engaged in ACP discussions. METHODS: All patients admitted to the EGS service in 2019 were included. The primary outcome was having electronic health record ACP documentation (advance directive, physician order for life-sustaining treatment form [POLST], or ACP note). Multivariate analysis was conducted to identify predictors of ACP. RESULTS: Among 734 patients, the prevalence of ACP on admission was 15% (n = 109), and the prevalence of ACP completed during the hospitalization was 6% (n = 44). Only 27% (n = 12) of inpatient ACP was completed in the hospital before EGS procedures. Most documentation included advanced directives and POLST uploaded before admission (60%, n = 93), and 39 (22%) constituted ACP notes by the surgical team. Multivariable analysis demonstrated increasing age, Medicaid or Medicare insurance, increased length of stay, and institution-concordant primary care were associated with an increased odds of having ACP (Fig. 1); low English language proficiency, an increasing neighborhood deprivation index, and a higher Charlson Comorbidity score were all associated with lower odds of having ACP documentation (Fig. 1).Figure 1CONCLUSION: Integration of ACP for patients receiving EGS care is limited, with significant variation in terms of type of documentation. Little documentation is done in the context of their acute surgical condition. Further study is needed to identify opportunities and barriers to increasing ACP uptake into EGS workflows.

EGS plus: Predicting futility in LVAD patients with emergency surgical disease

BackgroundWhile emergent, non-cardiac surgery can be safely performed in LVAD patients, the inherent perioperative challenges of these rare procedures and the perception that these patients may be poor surgical candidates can contribute to reluctance to perform necessary emergency general surgery (EGS) procedures. We, therefore, sought to identify predictors of inpatient mortality to assist perioperative decision-making. MethodsThe Nationwide Inpatient Sample (2010-2015Q3) was used to identify patients with previously placed LVADs with a subsequent EGS admission diagnosis. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day mortality, and a risk-adjusted probability of death was calculated for significant patient subgroups across age. Additional demographic variables were included in the regression due to clinical relevance. ResultsThere were 1805 (weighted) LVAD-EGS patients with an overall mortality rate of 11%. Independent predictors of mortality were intestinal ischemia and sepsis present on admission. Patients older than 70 with sepsis had an 80% probability of in-hospital mortality (10.6 OR, 1.70–65.5 95% CI) while those over 70 presenting with intestinal ischemia had a 38% probability of death (3.6 OR, 1.50–8.78 95% CI). Mortality risk for younger patients with sepsis was still approximately 50%. ConclusionOlder LVAD patients presenting with either sepsis or intestinal ischemia have a substantial mortality risk while younger patients have a modest risk. These results can be used to guide treatment discussions when emergency surgery is being considered in LVAD patients.

Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries

INTRODUCTION: Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after natural disasters, its ability to identify similar groups of patients after emergency general surgery is unknown. We aimed to examine the association between SVI and outcomes after emergency general surgery. METHODS: Cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census track level of residence. Risk-adjusted outcomes (30-day mortality, serious complication, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status, household composition/disability, minority status/language, and housing type/transportation). RESULTS: Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rate of 30-day mortality (8.6% vs 8.1%; adjusted odds ratio [OR] 1.07; p < 0.001), serious complication (20.7% vs 18.4%; OR 1.17; p < 0.001), and readmission (16.1% vs 15.0%; OR 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the housing/transportation subtheme. CONCLUSION: National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting housing/transportation may help alleviate these disparities.