Emergency General Surgery Procedures Research Articles

Emergency general surgery outcomes at safety net hospitals

BackgroundThe United States hospital safety net is defined by the Agency for Healthcare Research and Quality as the top decile of hospitals, which see the greatest proportion of uninsured patients. These hospitals provide important access to health care for uninsured patients but are commonly believed to have worse outcomes. The aim of this study was to compare the outcomes of emergency general surgery procedures performed at safety net and nonsafety net hospitals. Material and methodsThe Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2008–2010 was used to create a cohort of inpatients who underwent emergency appendectomy, cholecystectomy, or herniorrhaphy. Outcomes measured included length of stay, charge, cost, death in hospital, complications, and failure to rescue (FTR). Univariate and logistic regression analysis was performed to associate variables with outcomes. ResultsA total of 187,913 emergency general surgery cases were identified, 11.5% of which were performed at safety net hospitals. The safety net cohort had increased length of stay but lower mean charge and cost. Age, comorbidity score, black race, male gender, and Medicaid and Medicare insurance were associated with mortality, complication, and FTR. Lower socioeconomic status was associated with mortality and complication. Safety net status was positively associated with complication but not mortality or FTR. ConclusionsSafety net hospitals had higher complication rates but no difference in FTR or mortality. This may mean that the hospitals are able to effectively recognize and treat patient complications and do so without increased cost.

Trainee participation is associated with adverse outcomes in emergency general surgery: an analysis of the National Surgical Quality Improvement Program database.

To identify whether resident involvement affects clinically relevant outcomes in emergency general surgery. Previous research has demonstrated a significant impact of trainee participation on outcomes in a broad surgical patient population. We identified 141,010 patients who underwent emergency general surgery procedures in the 2005-2010 Surgeons National Surgical Quality Improvement Program database. Because of the nonrandom assignment of complex cases to resident participation, patients were matched (1:1) on known risk factors [age, sex, inpatient status, preexisting comorbidities (obesity, diabetes, smoking, alcohol, steroid use, coronary artery disease, chronic renal failure, pulmonary disease)] and preoperatively calculated probability for morbidity and mortality. Clinically relevant outcomes were compared with a t or χ test. The impact of resident participation on outcomes was assessed with multivariable regression modeling, adjusting for risk factors and operative time. The most common procedures in the matched cohort (n = 83,790) were appendectomy (39.9%), exploratory laparotomy (8.8%), and adhesiolysis (6.6%). Trainee participation is independently associated with intra- and postoperative events, wound, pulmonary, and venous thromboembolic complications, and urinary tract infections. Trainee participation is associated with adverse outcomes in emergency general surgery procedures.

Implementation of an acute care emergency surgical service: a cost analysis from the surgeon’s perspective

Acute care surgical services provide comprehensive emergency general surgical care while potentially using health care resources more efficiently. We assessed the volume and distribution of emergency general surgery (EGS) procedures before and after the implementation of the Acute Care and Emergency Surgery Service (ACCESS) at a Canadian tertiary care hospital and its effect on surgeon billings. This single-centre retrospective case-control study compared adult patients who underwent EGS procedures between July and December 2009 (pre-ACCESS), to those who had surgery between July and December 2010 (post-ACCESS). Case distribution was compared between day (7 am to 3 pm), evening (3 pm to 11 pm) and night (11 pm to 7 am). Frequencies were compared using the χ(2) test. Pre-ACCESS, 366 EGS procedures were performed: 24% during the day, 55% in the evening and 21% at night. Post-ACCESS, 463 operations were performed: 55% during the day, 36% in the evening and 9% at night. Reductions in night-time and evening EGS were 57% and 36% respectively (p < 0.001). Total surgeon billings for operations pre- and post-ACCESS were $281 066 and $287 075, respectively: remuneration was $6008 higher post-ACCESS for an additional 97 cases (p = 0.003). Using cost-modelling analysis, post-ACCESS surgeon billing for appendectomies, segmental colectomies, laparotomies and cholecystectomies all declined by $67 190, $125 215, $66 362, and $84 913, respectively (p < 0.001). Acute care surgical services have dramatically shifted EGS from nighttime to daytime. Cost-modelling analysis demonstrates that these services have cost-savings potential for the health care system without reducing overall surgeon billing.

Preoperative fasting: current practice and areas for improvement

Preoperative fasting aims to increase patient safety by reducing the risk of adverse events during general anaesthesia. However, prolonged fasting may be associated with dehydration, hypoglycaemia and electrolyte imbalance as well as patient discomfort. We aimed to examine compliance with the current best practice guidelines in a large surgical unit and to identify areas for improvement. Adult patients undergoing elective and emergency general, orthopaedic, gynaecology and vascular surgery procedures in the Royal Infirmary of Edinburgh were surveyed over a 3-month period commencing November 2011. A standardised questionnaire was used to collect information on the duration of preoperative fasting and the advice administered by medical and nursing staff. 292 patients were included. Median fast from solids was 13.5h for elective patients (IQR 11.5-16) and 17.38h for emergency patients (IQR 13.68-28.5h). Similarly, the median fast from fluids was 9.36h for elective patients (IQR 5.38-12.75h) and 12.97h for emergency patients (IQR 8.5-16.22h). The instructions that elective patients received contributed to prolonged fasting times. The median fast for elective patients fully compliant with fasting advice would be 10h for solids (IQR 8.75-12h) and 6.25h (IQR 3.83-9.25h) for clear fluids. Elective patients fasted for longer than recommended confirming that clinical practice is slow to change. The use of universal fasting instructions and patient choice are factors that unnecessarily prolong preoperative fasting, which however appears to be multifactorial. Service improvement by abbreviation of the observed fasting periods will rely on targeted staff education and effective clinical communication by provision of written information for both elective and emergency surgical patients. The routine use of preoperative nutritional supplements may need to be re-examined when further evidence is available.

Variation in Quality of Care after Emergency General Surgery Procedures in the Elderly

Variation in Quality of Care after Emergency General Surgery Procedures in the Elderly

Demographic Transition Calls for the Adaptation of Healthcare: The Example of Emergency Surgical Procedures

Evaluation of: Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Variation in quality of care after emergency general surgery procedures in the elderly. J. Am. Coll. Surg. 212(6), 1039–1048 (2011). It is well known that most countries are confronted with a demographic transition entailing a greater proportion of people in the upper age bracket. This demographic transition calls for societal adaptation in several areas. In particular the healthcare system needs to rethink its knowledge base, how to apply various medical and surgical interventions as well as how healthcare is organized. In addition, the interventions applied in different health conditions need to be questioned regarding their adaptation to the situation of people in the later stages of the lifespan and to the result of the aging process. The knowledge base for various types of medical or surgical interventions is poor, mainly because research tends to exclude elderly people from studies on the grounds of comorbidities or other functional problems. Thus studies may have very good internal validity but poor external validity when it comes to informing clinical practice about procedures for elderly patients. The aging process, including less reserve capacity in most organs, as well as the morbidities and comorbidities, also makes the individual more vulnerable to the interventions applied. Thus the healthcare system needs to accept and act upon the fact that most of their patients will be people in the upper age bracket. The improved longevity taking place in most countries in the world is a success story but it also brings with it challenges of treating people who are more vulnerable to a variety of complications.

Variation in Quality of Care after Emergency General Surgery Procedures in the Elderly

The elderly (age ≥65 years) comprise an increasing proportion of patients undergoing emergency general surgery (EGS) procedures and have distinct needs compared with the young. We postulated that the needs of the elderly require different processes of care than those required for the young to assure optimal outcomes. To explore this hypothesis, we evaluated 30-day outcomes following EGS procedures in the young and the elderly and determined whether hospital performance was consistent across these 2 age strata. With data from the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2008), regression models were constructed for serious morbidity and mortality for all patients undergoing EGS procedures and separately for young and elderly patients. These models allowed for estimation of the risk of adverse outcomes associated with advanced age and the generation of hospital-level observed to expected (O/E) ratios. We evaluated the correlation between hospital O/E ratios for the young and the elderly and the concordance of outlier status (hospitals with CIs of O/E ratios excluding 1) with weighted κ across these 2 age groups. Among 68,003 procedures at 186 hospitals, elderly patients had a higher crude and adjusted risk for serious morbidity (27.9% versus 9.7%, p < 0.0001; odds ratio 1.17, 95% CI 1.10 to 1.24) and mortality (15.2% versus 2.5%, p < 0.0001; odds ratio 2.29, 95% CI 2.09 to 2.51). When outcomes for elderly versus younger patients were compared, there was fair to moderate agreement on hospital performance for serious morbidity (r = 0.43; κ = 0.30) but not for mortality (r = 0.10; κ = 0.17). Elderly patients are at substantially greater risk for adverse events following EGS procedures. Hospitals had only slight agreement in mortality outcomes in the elderly compared with those in young patients. Processes of care that may account for this disparity should be further investigated.

Malpractice Risk and Cost Are Significantly Reduced after Tort Reform

Rising medical malpractice premiums have reached a crisis point in many areas of the United States. In 2003 the Texas legislature passed a comprehensive package of tort reform laws that included a cap at $250,000 on noneconomic damages in most medical malpractice cases. We hypothesized that tort reform laws significantly reduce the risk of malpractice lawsuit in an academic medical center. We compared malpractice prevalence, incidence, and liability costs before and after comprehensive state tort reform measures were implemented. Two prospectively maintained institutional databases were used to calculate and characterize malpractice risk: a surgical operation database and a risk management and malpractice database. Risk groups were divided into pretort reform (1992 to 2004) and post-tort reform groups (2004 to the present). Operative procedures were included for elective, urgent, and emergency general surgery procedures. During the study period, 98,513 general surgical procedures were performed. A total of 28 lawsuits (25 pre-reform, 3 postreform) were filed, naming general surgery faculty or residents. The prevalence of lawsuits filed/100,000 procedures performed is as follows: before reform, 40 lawsuits/100,000 procedures, and after reform, 8 lawsuits/100,000 procedures (p < 0.01, relative risk 0.21 [95% CI 0.063 to 0.62]). Virtually all of the liability and defense cost was in the pretort reform period: $595,000/year versus $515/year in the postreform group (p < 0.01). Implementation of comprehensive tort reform in Texas was associated with a significant decrease in the prevalence and cost of surgical malpractice lawsuits at one academic medical center.

Effect Of Trauma Center Status on 30-Day Outcomes After Emergency General Surgery

Trauma surgeons increasingly care for emergency general surgery (EGS) patients. The extent to which trauma center (TC) performance improvement translates into improved quality for EGS is unknown. We hypothesized that EGS outcomes in TCs would be similar to outcomes in non-trauma centers (NTC); failure to support our hypothesis suggests that the effects of trauma performance improvement have extended beyond trauma patients. We retrospectively studied EGS procedures at TCs versus NTCs among American College of Surgeons National Surgical Quality Improvement Program participants (2005-2008). Thirty-day outcomes were overall morbidity, serious morbidity, and mortality. TC versus NTC outcomes were compared using regression modeling, observed-to-expected (O/E) ratios (among hospitals submitting ≥20 EGS procedures), and outlier status (hospitals whose O/E confidence interval excludes 1.0). Of 68,003 patients at 222 hospitals, 42,264 (62.2%) were treated at 121 TCs; 25,739 (37.8%) were treated at 101 NTCs. TCs had significantly higher overall morbidity (21.4% versus 17.2%; p < 0.0001), serious morbidity (15.8% versus 12.3%; p < 0.0001), and mortality (6.4% versus 4.8%; p < 0.0001) than NTCs. On adjusted analyses, TC status was a significant predictor of overall morbidity (odds ratio = 1.11; 95% CI, 1.01-1.21), but not serious morbidity (odds ratio = 1.08; 95% CI, 0.98-1.19) or mortality (odds ratio = 0.92; 95% CI, 0.82-1.04). Among 211 hospitals assigned O/E ratios, TCs were more likely, although not significantly so, to be high outliers for overall morbidity (7.6% versus 4.3%; p = 0.017), serious morbidity (5.1% versus 4.3%; p = 0.034), and mortality (3.4% versus 2.2%; p > 0.099). Although overall morbidity tended to favor NTCs, mortality was no different. This suggests that the trauma performance improvement processes have not been applied to EGS patients, despite being cared for by similar providers. Despite having processes for trauma, there remains the opportunity for quality improvement for EGS care.

Comparison of Hospital Performance in Emergency Versus Elective General Surgery Operations at 198 Hospitals

Surgical quality improvement has focused on elective general surgery (ELGS) outcomes despite the substantial risk associated with emergency general surgery (EMGS) procedures. Furthermore, any differences in the quality of care provided to EMGS versus ELGS patients are not well described. We compared risk factors and risk-adjusted outcomes associated with EMGS and ELGS procedures to assess whether hospitals have comparable outcomes across these procedures. Using American College of Surgeons National Surgical Quality Improvement Program data (2005 to 2008), regression models were constructed for 30-day overall morbidity, serious morbidity, and mortality among all patients, EMGS patients, and ELGS patients. Observed-to-expected (O/E) ratios were calculated from models based on EMGS or ELGS patients. Association of hospital performance after EMGS versus ELGS procedures was assessed by evaluating correlations of O/E ratios; agreement in outlier status (hospitals where O/E confidence intervals [CI] do not overlap 1.0) was evaluated with weighted kappa. Of 473,619 procedures, 67,445 (14.2%) patients underwent an EMGS procedure. EMGS patients were more likely to experience any morbidity (odds ratio [OR] 1.20; 95% CI 1.16 to 1.23), serious morbidity (OR 1.26; 95% CI 1.21 to 1.30), and mortality (OR 1.39; 95% CI 1.30 to 1.48). Correlation between O/E ratios for EMGS and ELGS were moderate to low (overall morbidity = 0.48, p < 0.0001; serious morbidity = 0.41, p < 0.0001, mortality = 0.18, p = 0.01). Outlier status was not consistent across EMGS and ELGS, with only slight agreement (overall morbidity = 0.18, p < 0.0001; serious morbidity = 0.16, p = 0.001, mortality = 0.19, p = 0.01). EMGS patients are at substantially greater risk than ELGS patients for adverse events. Hospitals do not appear to have highly consistent performance across EMGS and ELGS outcomes. Processes of care that afford improved outcomes to EMGS patients need to be identified and disseminated.

Comparison of 30-day outcomes after emergency general surgery procedures: Potential for targeted improvement

Patients who undergo emergency operations represent a high-risk population and have been shown to have a high risk of poor outcomes. Little is known, however, about the variability in the quality of emergency general surgical care across hospitals or within hospitals across different procedures. The objectives of this study were to identify risk factors associated with adverse events, to compare 30-day outcomes after 3 common emergency general surgery procedures within and across hospitals, and thus, to determine whether the quality of emergency surgical care is procedure-dependent or intrinsic to other aspects of the hospital environment. Patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 95 hospitals that submitted at least 20 of each procedure were identified in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Project database. Outcomes of interest included 30-day overall morbidity and serious morbidity/mortality. Step-wise logistic regression generated patient-level predicted probabilities of an outcome. Based on the expected probabilities, observed to expected (O/E) ratios for each outcome, after each of the 3 procedures, were calculated for each hospital. Hospitals were divided into terciles based on O/E ratios. The agreement on hospital outcomes performance for overall morbidity and serious morbidity/mortality after appendectomy, cholecystectomy, and colorectal resection was assessed using weighted kappa statistics. Of the 30,788 appendectomies, 1,984 (6.44%) patients had any morbidity, and 1,140 (3.70%) patients had a serious morbidity or died. Of the 5,824 cholecystectomies, 503 (8.64%) patients had any morbidity, and 371 (6.37%) patients had a serious morbidity or died. Of the 8,990 colorectal resections, 4,202 (46.74%) patients had any morbidity, and 3,736 (41.56%) patients had a serious morbidity or died. For overall morbidity, O/E ratios for appendectomy ranged from 0.26 to 2.36; O/E ratios for cholecystectomy ranged from 0 to 3.04; O/E ratios for colorectal resection ranged from 0.45 to 1.51. For serious morbidity/mortality, O/E ratios for appendectomy ranged from 0.23 to 2.54; O/E ratios for cholecystectomy ranged from 0 to 4.28; O/E ratios for colorectal resection ranged from 0.59 to 1.75. Associations of risk-adjusted hospital outcomes based on tercile rank between procedures demonstrated slight but significant agreement for both overall morbidity (weighted kappa between 0.20 and 0.22) and serious morbidity/mortality (weighted kappa between 0.18 and 0.22). Despite this, 7 (7.4%) hospitals for overall morbidity and 9 (9.5%) hospitals for serious morbidity/mortality were rated in the highest (best) tercile for all procedures. Eight (8.4%) hospitals for overall morbidity and 8 (8.4%) hospitals for serious morbidity/mortality were rated in the lowest tercile for all procedures. Emergency general surgery procedures, particularly colorectal resections, were associated with substantial 30-day overall morbidity and serious morbidity/mortality. Most hospitals did not have consistent risk-adjusted outcomes across all 3 procedures, but for a substantive minority of institutions (7-10%), good or bad performance was generalizable across procedures. Individual hospitals should examine their procedure-specific outcomes after emergency general surgery operations to focus quality improvement initiatives appropriately.

Comparison of Thirty-Day Outcomes after Emergency General Surgery Procedures: Areas for Targeted Improvement

Introduction: Patients who undergo emergency surgery represent a high-risk population and have been shown to have poor outcomes. However, little is known about the variability in the quality of emergency general surgical care across hospitals. The objectives of this study were to compare 30-day outcomes after three common emergency general surgery procedures and to determine whether the quality of emergency surgical care is procedure-dependent or intrinsic to other aspects of the hospital environment. Methods: Patients who underwent emergency appendectomy, cholecystectomy, or colectomy at 95 hospitals that reported at least 20 of each procedure were identified in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Outcomes of interest included 30-day overall morbidity and serious morbidity/mortality. Forward step-wise multivariable logistic regression models identified variables included in hierarchical models. Based upon the expected probabilities of the outcome derived from the hierarchical model, observed to expected (O/E) ratios for each outcome after the three procedures were calculated for each hospital. Hospitals were divided into three roughly equal groups based upon O/E ratios (Figure). Agreements on hospital outcomes for overall morbidity and serious morbidity/mortality after appendectomy, cholecystectomy, and colectomy were assessed using the kappa statistic and the Kendall's coefficient of concordance. Results: Of the 30,788 appendectomies, 1,984 (6.4%) patients had any morbidity, and 1,143 (3.7%) patients had a serious morbidity or died. Of the 5,824 cholecystectomies, 503 (8.6%) patients had any morbidity, and 369 (6.3%) patients had a serious morbidity or died. Of the 8,992 colectomies, 4,200 (46.7%) patients had any morbidity, and 3,737 (41.6%) patients had a serious morbidity or died. For overall morbidity, O/E ratios for appendectomy ranged from 0.31 to 2.52; O/E ratios for cholecystectomy ranged from 0 to 3.2; O/E ratios for colectomy ranged from 0.43 to 1.53. For serious morbidity/mortality, O/E ratios for appendectomy ranged from 0.21 to 2.93: O/E ratios for cholecystectomy ranged from 0 to 4.32; O/E ratios for colectomy ranged from 0.6 to 1.63. Hospitals outcomes based upon tercile rank after one procedure were not similar to those after the other procedures for either overall morbidity (kappa=0.13) or serious morbidity/mortality (kappa=0.16). Only nine (9.4%) hospitals for overall morbidity and nine (9.4%) hospitals for serious morbidity/mortality were rated in the highest tercile for all procedures. Four (4.2%) hospitals for overall morbidity and seven (7.4%) hospitals for serious morbidity/mortality were rated in the lowest tercile for all procedures. Conclusion: All three emergency general surgery procedures were associated with substantial 30-day overall morbidity and serious morbidity/mortality. Most hospitals did not have uniform outcomes across all three procedures. Individual hospitals should examine their procedure-specific outcomes after emergency general surgeries to focus quality improvement initiatives appropriately.