Emergency General Surgery Procedures Research Articles

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.

Outcomes after single-look trauma laparotomy: A large population-based study.

Outcomes following damage control laparotomy for trauma have been studied in detail. However, outcomes following a single operation, or "single-look trauma laparotomy" (SLTL), have not. We evaluated the association between SLTL and both short-term and long-term outcomes in a large population-based data set. The California Office of Statewide Health Planning and Development patient discharge database was evaluated for calendar years 2007 through 2014. Injured patients with SLTL during their index admission were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Diagnosis and procedure codes were used to identify specific abdominal organ injuries, surgical interventions, and perioperative complications. Subsequent acute care admissions were examined for postoperative complications and related surgical interventions. Clinical characteristics, injuries, surgical interventions, and outcomes were analyzed by mechanism of injury. There were 2113 patients with SLTL during their index admission; 712 (33.7%) had at least one readmission to an acute care facility. Median time to first readmission was 110 days. Penetrating mechanism was more common than blunt (60.6% vs. 39.4%). Compared to patients with penetrating injury, blunt-injured patients had a significantly higher median Injury Severity Score (9 vs. 18, p < 0.0001) and a significantly higher mortality rate during the index admission (4.1% vs. 27.0%, p < 0.0001). More than 30% of SLTL patients requiring readmission had a surgery-related complication. The most common primary reasons for readmission were bowel obstruction (17.7%), incisional hernia (11.8%), and infection (9.1%). There was no significant association between mechanism of injury and development of surgery-related complications requiring readmission. Patients with SLTL had postinjury morbidity and mortality, and more than 30% required readmission. Complication rates for SLTL were comparable to those reported for emergency general surgery procedures. Patients should be educated on signs and symptoms of the most common complications before discharge following SLTL. Further investigation should focus on the factors associated with the development of these complications. Prognostic and epidemiologic study, level III.

The five-point modified frailty index (mfi-5) predicts surgical outcomes in pancreatic ductal adenocarcinoma (pdac) patients undergoing pancreaticoduodenectomy

Background: Predicting surgical outcomes has become increasingly important. Multiple predictive models have emerged, however, their adoption into practice has been slow. Nowhere is the need more pressing for identifying appropriate surgical candidates than in complex surgical procedures such as pancreaticoduodenectomies (“Whipple procedures”). Velanovich et. al. reported an eleven-point modified frailty index (mFI) using variables collected by the National Surgical Quality Improvement Project (NSQIP) to predict outcomes for emergency general surgery procedures in elderly patients. Modification of the mFI has resulted in a simplified 5-point version mFI (mFI-5). This study evaluates the predictability of the mFI-5 in pancreatic cancer patients undergoing pancreaticoduodenectomies. Methods: We conducted a retrospective study of patients undergoing pancreticoduodenectomy (CPT: 48150, 48152, 48153, and 48154) for PDAC using the ACS-NSQIP Participant User File from 2014-2016 to evaluated frailty and its relationship to postoperative outcomes. Using the mFI-5, each patient was assigned a numeric score (0 or 1) dependent on the presence of the following preoperative variables: functional status, diabetes, history of COPD, history of CHF, or hypertension requiring medication. Patients were then categorized, on a scale of 0 to 5, as no frailty (0), low frailty (1-2), intermediate frailty (3-4), or frail (5). Primary outcomes were evaluated according the following variables: length of stay (LOS), unplanned return to OR (RTOR), 30-day readmission, and 30-day mortality. Results: 6040 patients (age 20–89) were identified with no (37.5%), low (61.2%), or intermediate frailty (1.3%). There were no patients identified within the cohort identified within the frailty 5 category. A significant age difference was noted between the no (63.1), low (68.2), and intermediate (69.2) frailty groups (p < 0.0001). There were fewer women identified in the low and intermediate frailty groups compared to the no frailty group (p = 0.0001). Table 1 depicts the surgical outcomes according to the mFI-5 classifications. LOS was greater in the low and intermediate frailty group compared to the no frailty groups (p < 0.0001). Readmission rates were greater in the intermediate frailty group than in the no frailty group (24.7% vs 14.0%, p = 0.014). Although the 30-day mortality was greater in the low (2.6%) and intermediate (5.2%) frailty groups than in the no frailty group (1.4%), it was only statistically significantly different in the low frailty group. Conclusion: The small subset of preoperative medical co-morbidities included in the mFI-5 significantly predict differences in postoperative outcomes such as longer median LOS, readmission rates, and mortality between frailty groups. The mFI-5 is a simple and excellent predictor of outcome in PDAC patients undergoing pancreaticoduodenectomy. A larger study, including additional patients with higher frailty, is required to fully elucidate the validity of the mFI-5 for predicting surgical outcomes within the intermediate frailty or frail groups. A concise clinical prediction tool such as the mFI-5 has the ability to be easily widely applied in surgical practice to aid surgeons in making appropriate risk stratifications for patients with pancreatic cancer undergoing pancreticoduodenectomy.

Symptomatic human immunodeficiency virus-infected patients have poorer outcomes following emergency general surgery: A study of the nationwide inpatient sample.

The impact of human immunodeficiency virus (HIV) infection on outcomes following common emergency general surgery procedures has not been evaluated since the widespread introduction of highly active antiretroviral therapy. A retrospective cohort study was conducted using the Nationwide Inpatient Sample. Records of patients who underwent laparoscopic or open appendectomy, cholecystectomy, or colon resection after emergency admission from 2004 to 2011 were obtained. Outcomes analyzed included in-hospital mortality, length of stay, total charges, and selected postoperative complications. Patients were divided among three groups, HIV-negative controls, asymptomatic HIV-positive patients, and symptomatic HIV/acquired immune deficiency syndrome (AIDS) patients. Data were analyzed using χ and multivariable regression with propensity score matching among the three groups, with p value less than 0.05 significant. There were 974,588 patients identified, of which 1,489 were HIV-positive and 1,633 were HIV/AIDS-positive. The HIV/AIDS patients were more likely to die during their hospital stay than HIV-negative patients (4.4% vs. 1.6%, adjusted odds ratio, 3.53; 95% confidence interval [CI], 2.67-4.07; p < 0.001). The HIV/AIDS patients had longer hospital stays (7 days vs. 3 days; adjusted difference, 3.66 days; 95% CI, 3.53-4.00; p < 0.001) and higher median total charges than HIV-negative patients (US $47,714 vs. US $28,405; adjusted difference, US $15,264; 95% CI, US $13,905-US $16,623; p < 0.001). The HIV/AIDS patients also had significantly increased odds of certain postoperative complications, including sepsis, septic shock, pneumonia, urinary tract infection, acute renal failure and need for transfusion (p < 0.05 for each). Differences persisted irrespective of case complexity and over the study period. Asymptomatic HIV-positive patients had outcomes similar to HIV-negative patients. The HIV/AIDS patients have a greater risk of death, infectious, and noninfectious complications after emergency surgery regardless of operative complexity and despite advanced highly active antiretroviral therapy. Patients who have not developed advanced disease, however, have similar outcomes to HIV-negative patients. Prognostic and epidemiologic study, level III.

Emergency general surgery procedures in hematopoietic stem cell transplant recipients

BackgroundOutcomes of emergency general surgery (EGS) procedures on hematopoietic stem cell transplant (HST) recipients have not been defined in a large, national database. Whether EGS during HST engraftment admission, or in HST patients with graft versus host disease (GVHD) results in worse outcomes is unknown. MethodsThe National Inpatient Sample (NIS) was examined for patients with a history of BMT between 2001 and 2014. ResultsThere were 520,000 HST admissions meeting inclusion criteria, of which, 14,143 (2.7%) required EGS. Of those requiring EGS, 378 (2.7%) were during engraftment admission and 13,765 (97.3%) on subsequent admission. For those requiring EGS during subsequent admission, 9,920 (72.1%) had a history of GVHD and 3,845 (27.9%) did not. On multivariate analysis, requirement of EGS was associated with mortality (OR: 1.71, 95%CI: 1.47–1.99, p < 0.001). For patients requiring EGS, engraftment admission or GVHD was not associated with mortality. ConclusionsWhile EGS results in worse survival for the HST population, patients in their engraftment admission do not appear to be at increased mortality risk. In addition, GVHD does not worsen survival.

Emergency general surgery in geriatric patients: How should we evaluate hospital experience?

As the aging American population poses unique challenges to acute care services, we determined if either hospital proportion or annual volume of geriatric patients undergoing emergency general surgery (EGS) procedures is associated with outcomes. Using criteria from the American Association of the Surgery of Trauma, we identified five EGS procedures in the 2012-2015 Nationwide Inpatient Sample common in geriatric patients (65+ years). We defined hospital proportion as the fraction of geriatric EGS patients divided by all EGS patients, where volume was the raw number of geriatric EGS patients. We then divided hospitals into quartiles both by proportion and then by volume of geriatric patients. Multivariable logistic regressions compared four outcomes between these quartiles: mortality, complications, failure to rescue (FTR; death after a complication), and extended length of stay (LOS; procedure-specific top decile of patients). We identified 25,084 complex EGS procedures in geriatric patients at 3,528 hospitals (mortality, 10.6%; complications, 30.5%; FTR, 27.7%; extended LOS, 9.1%). The median hospital proportion of geriatric patients among EGS procedures was 42.8% (interquartile range, 33.3-52.2%), whereas the median hospital geriatric EGS volume after nationwide weighting was 40 per year (interquartile range, 20-70/year). After adjustment, the lowest hospital proportion quartile relative to the highest was associated with adverse outcomes: mortality (odds ratio, 1.21 [95% confidence interval, 1.03-1.44]), complications (1.16 [1.05-1.29]), FTR (1.32 [1.08-1.63]), and extended LOS (1.30 [1.12-1.50]). The lowest volume quartile relative to the highest was not associated with adverse outcomes. As the hospital proportion of geriatric patients increased by 10%, the odds of all adverse outcomes decreased: mortality by 7%, complications by 4%, FTR by 9%, and extended LOS by 8%. When accounting for both, hospital proportion of geriatric EGS patients but not hospital volume is associated with postoperative outcomes, having important implications for quality improvement initiatives, benchmarking endeavors, and health services research. Care management, level IV; prognostic, level III.

Transferred Emergency General Surgery Patients Are at Increased Risk of Death: A NSQIP Propensity Score Matched Analysis

Emergency general surgery (EGS) encompasses high-risk patients undergoing high-risk procedures. Admission source, particularly interhospital transfer, is rarely accounted for in clinical performance benchmarking. Our goal was to assess the impact of transfer status on outcomes after EGS. This was a retrospective analysis of the American College of Surgeons NSQIP database (2005 to 2014). All inpatients that underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally were included. Admission source was classified as directly admitted vs transferred from an outside emergency department or an acute care facility. The primary outcomes were overall mortality, overall morbidity, and major morbidity. A 3:1 propensity score matched analysis was used to determine the association of admission source with outcomes. Subgroup analysis was performed for high- and low-risk EGS procedures. A total of 222,519 EGS admissions were identified, of which 15,232 (6.8%) were transfers. Mean age was 46 years and 51.4% were female. Overall mortality was 3.1% for the entire cohort and 10.8% within the transfer group. After propensity score matched analysis for 33 clinical and demographic variables, transferred patients had higher rates of overall mortality (odds ratio 1.01; 95% CI 1.01 to 1.02), higher overall morbidity (odds ratio 1.07; 95% CI 1.05 to 1.09), and major morbidity (odds ratio 1.06; 95% CI 1.04 to 1.08) compared with directly admitted patients. After rigorous risk adjustment, interhospital transfer status has a small effect on mortality and morbidity in the EGS population. This could suggest that it is reasonable to transfer patients and that regionalization of care should be encouraged.

Effect of diabetes mellitus on postoperative outcomes in patients undergoing emergency general surgery procedures.

Background: Diabetes Mellitus (DM) is a global health hazard affecting millions of people globally. A nationwide study conducted in Saudi Arabia showed the incidence and prevalence of DM were gradually increasing. Studies on the outcomes of emergency general surgery operations of diabetic patients are limited. The objective of this study is to compare the outcomes of diabetic patients undergoing emergency general surgery operations compared to those who are non-diabetic. Methods: Data for this cross-sectional study were collected using an observational clinical case series database, retrospectively, for patients undergoing emergency general surgery operations between July 2017 and December 2018 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were classified into diabetic and non-diabetic groups based on previous diagnosis at the time of presentation for their emergency procedure. Statistical analysis was utilized to investigate the association of diabetes with factors related to morbidity and mortality. Results: The total number of the participants was 325, wherein 177 (54.5%) were males. 185 (57%) were diabetic. We found significant association between diabetes mellitus and ICU admission and hospital readmissions compared to non-diabetic patients (odds ratio 1.772, relative risk 1.257 vs. 0.709, p=0.025). However, no statistically significant association was found between the diagnosis of diabetes and inhospital or 30-day mortality after emergency general surgery procedures. Conclusion: There are significant associations of the diagnosis of diabetes and worse postoperative outcomes in patients undergoing emergency general surgery procedures. Health care providers should give special attention as well as prompt and watchful perioperative care for this patients' population.

Racial Differences in Complication Risk Following Emergency General Surgery: Who Your Surgeon Is May Matter

BackgroundUnderstanding the mechanisms that lead to health-care disparities is necessary to create robust solutions that ensure all patients receive the best possible care. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing an emergency general surgery (EGS). Materials and methodsUsing the Florida State Inpatient Database, we analyzed patients who underwent one or more of seven EGS procedures from 2010 to 2014. The primary outcome was development of a major postoperative complication. To determine the individual surgeon effect on complications, we performed multilevel mixed effects modeling, adjusting for clinical and hospital factors, such as diagnosis, comorbidities, and hospital teaching status and volume. Results215,745 cases performed by 5816 surgeons at 198 hospitals were included. The overall unadjusted complication rate was 8.6%. Black patients had a higher adjusted risk of having a complication than white patients (odds ratio 1.12, 95% confidence interval 1.03-1.22). Surgeon random effects, when hospital fixed effects were held constant, accounted for 27.2% of the unexplained variation in complication risk among surgeons. This effect was modified by patient race; for white patients, surgeon random effects explained only 12.4% of the variability, compared to 52.5% of the variability in complications among black patients. ConclusionsThis multiinstitution analysis within a single large state demonstrates that not only do black patients have a higher risk of developing a complication after undergoing EGS than white patients but also surgeon-level effects account for a larger proportion of the between-surgeon variation. This suggests that the individual surgeon contributes to racial disparities in EGS.

Emergency General Surgery Procedures in the Bone Marrow Transplantation Population

Emergency General Surgery Procedures in the Bone Marrow Transplantation Population

The Importance of Safety-Net Hospitals in Emergency General Surgery

IntroductionSafety-net hospitals provide care to an inherently underprivileged patient population. These hospitals have previously been shown to have inferior surgical outcomes after complex, elective procedures, but little is known about how hospital payer-mix correlates with outcomes after more common, emergent operations. MethodsThe University HealthSystem Consortium database was queried for all emergency general surgery procedures performed from 2009 to 2015. Emergency general surgery was defined as the seven operative procedures recently identified as contributing most to the national burden. Only urgent and emergent admissions were included (n = 653,305). Procedure-specific cohorts were created and hospitals were grouped according to safety-net burden. Multivariate analyses were done to study the effect of safety-net burden on hospital outcomes. ResultsFor all seven emergency procedures, patients at hospitals with a high safety-net burden were more likely to be young and black (p < 0.01 each). Patients at high-burden hospitals had similar severity of illness scores to those at other hospitals. Compared with lower burden hospitals, in-hospital mortality rates at high-burden hospitals were similar or lower in five of seven procedures (p = NS or < 0.01, respectively). After adjusting for patient factors, high-burden hospitals had similar or lower odds of readmission in six of seven procedures, hospital length of stay in four of seven procedures, and cost of care in three of seven procedures (p = NS or < 0.01, respectively). ConclusionSafety-net hospitals provide emergency general surgery services without compromising patient outcomes or incurring greater healthcare resources. These data may help inform the vital role these institutions play in the healthcare of vulnerable patients in the USA.

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.

How has the Affordable Care Act changed outcomes in emergency general surgery?

Lack of insurance coverage increases complications and mortality from surgical procedures. The 2014 Affordable Care Act (ACA) Open Enrollment (OE) insured more Americans, but it is unknown if this improved outcomes from emergency general surgery (EGS) procedures. This study seeks to determine how ACA OE coverage changes outcomes in EGS. This is a retrospective review using the Nationwide Inpatient Sample database from 2012 to 2014. Patients aged 18 to 64 years undergoing EGS procedures were identified by International Classification of Diseases, Ninth Revision, codes. Medicare patients were excluded. Patient demographics, hospital characteristics, and Charlson comorbidity index were obtained. Outcomes were measured by mortality, complications, and calculated costs. Univariate and difference-in-differences multivariate analyses were performed to determine the effect of the ACA OE on EGS outcomes. A total of 304,110 EGS cases were identified. After Medicare patients were excluded, there were 275,425 cases. In 2014, Medicaid admissions increased 18.2% from 18,495 to 22,615 (p < 0.001) and self-pay admissions decreased 33% from 14,938 to 10,630 (p < 0.001). Mortality significantly increased for self-pay patients in 2014 from 0.81% to 1.22% (p < 0.001). Difference-in-differences analysis indicated that, after risk adjustment, the ACA OE was associated with a small reduction in mortality for insured patients (-0.12%, p = 0.034), increased complications (1.4%, p = 0.009), and increased wage-index adjusted mean costs (4.6%, p < 0.001). There was a significant increase in Medicare (+26.5%) and private (+12.2%, p < 0.001) insurance admissions in teaching hospitals, while nonteaching hospitals had fewer EGS admissions with a greater reduction in uninsured EGS admissions. The ACA OE created a significant reduction in uninsured EGS admissions but did not reduce EGS mortality. Mortality decreased in insured patients but increased in uninsured patients, indicating that the ACA OE primarily insured lower-risk patients. The ACA OE did increase cost and complications in insured admissions. Teaching hospitals saw the majority of the increase in Medicaid and private insurance EGS admissions. A national registry would improve future study of insurance policy on EGS outcomes. Economic analysis, level IV.

Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care.

Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality. Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile. Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01). Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes. Epidemiological, level III; Care management, level IV.

Understanding the “Weekend Effect” for Emergency General Surgery

BackgroundSeveral studies have identified a “weekend effect” for surgical outcomes, but definitions vary and the cause is unclear. Our aim was to better characterize the weekend effect for emergency general surgery using mortality as a primary endpoint. MethodsUsing data from the University HealthSystem Consortium from 2009 to 2013, we identified urgent/emergent hospital admissions for seven procedures representing 80% of the national burden of emergency general surgery. Patient characteristics and surgical outcomes were compared between cases that were performed on weekdays vs weekends. ResultsHospitals varied widely in the proportion of procedures performed on the weekend. Of the procedures examined, four had higher mortality for weekend cases (laparotomy, lysis of adhesions, partial colectomy, and small bowel resection; p < 0.01), while three did not (appendectomy, cholecystectomy, and peptic ulcer disease repair). Among the four procedures with increased weekend mortality, patients undergoing weekend procedures also had increased severity of illness and shorter time from admission to surgery (p < 0.01). Multivariate analysis adjusting for patient characteristics demonstrated independently higher mortality on weekends for these same four procedures (p < 0.01). ConclusionsFor the first time, we have identified specific emergency general surgery procedures that incur higher mortality when performed on weekends. This may be due to acute changes in patient status that require weekend surgery or indications for urgent procedures (ischemia, obstruction) compared to those without a weekend mortality difference (infection). Hospitals that perform weekend surgery must acknowledge and identify ways to manage this increased risk.

Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes

Emergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes. Using Maryland's Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons. We identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures. We found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.

Use of National Burden to Define Operative Emergency General Surgery.

Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures. To define a set of procedures accounting for at least 80% of the national burden of operative EGS. A retrospective review was conducted using data from the 2008-2011 National Inpatient Sample. Adults (age, ≥18 years) with primary EGS diagnoses consistent with the American Association for the Surgery of Trauma definition, admitted urgently or emergently, who underwent an operative procedure within 2 days of admission were included in the analyses. Procedures were ranked to account for national mortality and complication burden. Among ranked procedures, contributions to total EGS frequency, mortality, and hospital costs were assessed. The data query and analysis were performed between November 15, 2015, and February 16, 2016. Overall procedure frequency, in-hospital mortality, major complications, and inpatient costs calculated per 3-digit International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. The study identified 421 476 patient encounters associated with operative EGS, weighted to represent 2.1 million nationally over the 4-year study period. The overall mortality rate was 1.23% (95% CI, 1.18%-1.28%), the complication rate was 15.0% (95% CI, 14.6%-15.3%), and mean cost per admission was $13 241 (95% CI, $12 957-$13 525). After ranking the 35 procedure groups by contribution to EGS mortality and morbidity burden, a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide. These 7 procedures included partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy. Only 7 procedures account for most admissions, deaths, complications, and inpatient costs attributable to the 512 079 EGS procedures performed in the United States each year. National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures.

Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery.

Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist. To define readmission rates and identify risk factors for readmission after common EGS procedures. Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis. Thirty-day hospital readmission. Among 177,511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adjusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%). Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.

“Halo effect” in trauma centers: does it extend to emergent colectomy?

BackgroundTrauma centers (TCs) have been demonstrated to improve outcomes for some nontrauma surgical conditions, such as appendicitis, but it remains unclear if this extends to all emergency general surgery procedures. Using emergent colectomy in patients with diverticulitis as index condition, this study compared outcomes between TCs and nontrauma centers (NTCs). Materials and methodsThe Nationwide Emergency Department Sample (2006–2011) was queried for patients ≥16 y with diverticulitis who underwent emergency surgical intervention. Outcomes included mortality, total charges, and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for patient, procedure, and hospital-level characteristics. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively. ResultsA total of 25,396 patients were included, 5189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age and sex distribution were similar. Unadjusted proportional in-hospital mortality did not differ between TC and NTC; median charges and LOS were greater in TC. After adjusting, the odds of mortality were significantly higher in TC (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.02–1.51; P = 0.003) as were mean charges and LOS (P < 0.001). ConclusionsThe improved outcomes reported for other nontrauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for patient, procedure, and hospital-level characteristics. Future research is needed to assess differences in case mix between TC versus NTC and possible case-mix effects on outcomes to elucidate potential benefit of surgical care in a TC across the breadth of emergency general surgery conditions.

Certified acute care surgery programs improve outcomes in patients undergoing emergency surgery: A nationwide analysis.

Differences in outcomes among trauma centers (TCs) and non-TCs (NTCs) in patients undergoing emergency general surgery (EGS) are well established. However; the impact of development of certified acute care surgery (ACS) programs on patient outcomes remains unknown. The aim of this study was to evaluate outcomes in patients undergoing EGS across TCs, NTCs, and TCs with ACS (ACS-TC). National estimates for EGS procedures were abstracted from the National Inpatient Sample database. Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, as well as small and large bowel resections) were included. TCs were identified based on American College of Surgeons' verification. ACS-TC programs were recorded from the American Association for the Surgery of Trauma. Outcome measures were hospital length of stay, complications, and mortality. Regression analysis was performed after adjusting for age, sex, race, Charlson comorbidity index, and type of procedure. A total of 131,410 patients undergoing EGS were analyzed. Patients managed in ACS-TCs had shorter hospital stay (p = 0.045) and lower complication rate (p = 0.041) compared with patients managed in both TCs and NTCs. There was no difference in mortality in patients managed across the groups; however, there was a trend toward lower mortality in patients managed in ACS-TCs in comparison with TCs (p = 0.064) and NTCs (p = 0.089). The overall hospital costs were lower for patients managed in ACS-TCs compared with TCs (p = 0.036). TCs with ACS have improved outcomes in EGS procedures compared with both TCs and non-TCs. ACS training with the associated infrastructure standards may contribute to these improved outcomes. Therapeutic/care management study, level IV.