Emergency General Surgery Registry Research Articles

Development and implementation of an automated electronic health record-linked registry for emergency general surgery.

Despite adoption of the emergency general surgery (EGS) service by hospitals nationally, quality improvement (QI) and research for this patient population are challenging because of the lack of population-specific registries. Past efforts have been limited by difficulties in identifying EGS patients within institutions and labor-intensive approaches to data capture. Thus, we created an automated electronic health record (EHR)-linked registry for EGS. We built a registry within the Epic EHR at University of California San Diego for the EGS service. Existing EHR labels that identified patients seen by the EGS team were used to create our automated inclusion rules. Registry validation was performed using a retrospective cohort of EGS patients in a 30-month period and a 1-month prospective cohort. We created quality metrics that are updated and reported back to clinical teams in real time and obtained aggregate data to identify QI and research opportunities. A key metric tracked is clinic schedule rate, as we care that discontinuity postdischarge for the EGS population remains a challenge. Our registry captured 1,992 patient encounters with 1,717 unique patients in the 30-month period. It had a false-positive EGS detection rate of 1.8%. In our 1-month prospective cohort, it had a false-positive EGS detection rate of 0% and sensitivity of 85%. For quality metrics analysis, we found that EGS patients who were seen as consults had significantly lower clinic schedule rates on discharge compared with those who were admitted to the EGS service (85% vs. 60.7%, p < 0.001). An EHR-linked EGS registry can reliably conduct capture data automatically and support QI and research. Prognostic and epidemiological, level III.

Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues.

Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.

Laparoscopy is associated with decreased all-cause mortality in patients undergoing emergency general surgery procedures in a regional health system.

The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. Our integrated health care system's EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0years vs. 57.2 ± 17.6, p < 0.001) with similar BMI (29.7 ± 9.0kg/m2 vs. 28.8 ± 8.3, p < 0.001). Patients in the laparoscopic group had lower mean CCI score (1.6 ± 2.3 vs. 3.4 ± 3.2, p ≤ 0.0001). On multivariable analysis, open surgery had the highest association with inpatient mortality (OR 8.67, 4.23-17.75, p < 0.0001) and at all time points (30-, 90-day, 1-, 3-year). At all time points, conversion to open was found to be a statistically significant protective factor. Use of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.

Surgical Rescue in a High-volume Urban Emergency General Surgery Service at a Middle-income Country.

Introduction:The capacity for prompt “rescue” from death in patients with complications has become an important marker of the quality of care since mortality and morbidity have been identified as incongruous indicators. This study aims to describe the incidence of “surgical rescue” failure and the outcomes of emergency general surgery (EGS) patients at a large academic medical center.Materials and methods:In our high-volume surgical hospital, an electronic EGS registry was developed to automatically capture in-hospital information and outcomes from the Electronic Medical Record (EMR). Surgical complications were included in an online application and automatically captured in the electronic EGS registry, and prospectively screened from June to July 2017 for acute EGS surgical patients from operative procedures.Results:A total of 501 patients (average age: 53.9 ± 20.9, 56.5% female) underwent 882 EGS procedures. Thirteen patients (2.6%) of the 501 patients required “surgical rescue”, mainly for uncontrolled sepsis (43%) and anastomotic leakage (30%). The surgical rescue failure rate (inability to prevent death after a surgical complication) was 15.4%. Patients requiring critical care (OR = 3.3, IC 95%: 1.04, 10.5), hospital admission (p = 0.038), and hospital LOS (days) (p = 0.004) were significantly higher for the surgical rescue patients than for those without complications.Conclusion:Surgical failure to rescue rate was similar among high-volume EGS services, as has recently been described in the United States. The latest development and implementation of an electronic automatic captured EGS registry database in our academic medical center will serve to build best practices for “surgical rescue” and drive quality improvement programs.

The Obesity Paradox in Emergency General Surgery Patients.

Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. A total of 60604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7years, 64.2% >BMI 30kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

The evolution of emergency general surgery: its time for a dedicated program manager.

Emergency general surgery (EGS) is emerging as a distinct sub-specialty of acute care surgery but continues to exist without essential processes that drive modern trauma programs. An EGS-specific quality program was created with service-based Advanced Practice Provider (SB APP) administrative oversight, thus validating the need for a dedicated EGS program manager. In 2017, a quality structure was formalized with primary focus on scheduled quality meetings, peer review and outcomes review. All admission, service-specific dashboards, and readmission data were manually audited by SB APPs to confirm accuracy and identify opportunities for process improvement. Surgical quality metrics including patient volume, mortality, complications, readmission and infection prevention indicators, were reviewed by SBAPPs. Annual EMR data for all EGS patients was compared to data collected via manual review with a novel registry logic. Comparison of EMR generated data versus EGS registry data identified under-representation of total admissions: in 2016, the EMR identified 130 admissions with registry logic identifying 625 actual EGS admissions. The EMR identified 515 admissions in 2017 and 485 admission in 2018 with registry logic identifying 777 and 712, respectively. Review of readmission data revealed an error of 14 patients in 2017 and 11 patients in 2018. The quest to improve quality of care for the EGS patient requires timely review of high-quality, accurate data by dedicated and trained personnel. Our process revealed the vital functions of an EGS PM are crucial in the evolution of the EGS specialty. Level IV economic and value-based evaluations.

Characteristics and Outcomes of Drainage Versus Surgery First in Severe Pancreatitis.

Percutaneous drainage as the initial procedure for severe pancreatitis (SP) may not always be optimal. Our aim was to identify the characteristics of patients who failed percutaneous drainage and compare their outcomes with patients who underwent surgical intervention as the initial approach. A retrospective review of a prospectively collected emergency general surgery registry of patients admitted to a tertiary-care, academic center with the diagnosis of SP who underwent an intervention was performed (2010-2018). Patients were divided into successful drainage (SD), drainage failure (DF), and surgery first (SF) groups. DF was defined as the need for surgical intervention. The study included 129 patients. Fifty (38.8%) patients underwent SF as their initial management modality. Among 79 patients who underwent drainage, 34 (43.0%) were in the DF group and progressed to surgical intervention. Within that group, 19 (55.9%) underwent open necrosectomy. The DF group was more likely to have lower rates of peripancreatic fluid collections, a higher rate of necrotizing pancreatitis, and a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score when compared with the DS group. Mortality was higher in the DF and SF groups, and total length of stay and ICU length of stay were highest in the DF group. Patients who experience failure of drainage for SP have high morbidity and mortality rates and fare worse overall than patients who undergo surgery as the primary intervention. Patients with necrotizing pancreatitis and a higher APACHE II score might warrant surgical intervention over a drainage-first approach.

Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry.

The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes. A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases. In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications. National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.

Time for metrics in emergency surgical care - the role of an emergency surgery registry.

There is abundant local, national, and international evidence that clinical decision-making in emergency general surgery (EGS) is frequently sub-optimal, and this has a negative impact on the quality and safety of care and patient outcomes. The barriers to achieving high-quality, safe, and effective EGS care across health systems are manifold and multifactorial. It is suggested that emergency surgery registries may provide a suitable foundation to enable interventions that lead to improvements in quality in this area. Data from surgical registries may serve multiple purposes, including improving the quality of healthcare and the enhancement of patient safety. The increasing sophistication and analytic capabilities of clinical registries and databases contribute considerably in all of these domains due to their use of accurate, credible, risk-adjusted, and concurrent clinical data, which are acquired for these specific purposes. The emergency surgery outcomes advancement (eSOAP) project commenced during late 2018, with the aim of establishing the feasibility of prospective data capture on all EGS admissions and assessing the outcomes and impact of clinical pathways for patients admitted to EGS services in Letterkenny University Hospital (Republic of Ireland), Altnagelvin Hospital (Northern Ireland), and Raigmore Hospital (Scotland). eSOAP seeks to address deficits in EGS care by enabling an assessment of patient outcomes, enhancing the quality and safety of patient care, and providing an effective template for EGS registry development. It will achieve this through the provision of meticulous, valid, risk-adjusted, and concurrent clinical data. The comprehensive information within the eSOAP registry will promote transparency in respect of the functioning of individual surgical teams and services and increase understanding of the complex systems involved in the delivery of EGS care.

Review of an emergency general surgery process improvement program at a verified military trauma center.

Decreasing combat-based admissions to our military facility have made it difficult to maintain a robust trauma process improvement (PI) program. Since emergency general surgery (EGS) and trauma patients share similarities, we merged the care of our EGS and trauma patients into one acute care surgery (ACS) team. An EGS PI program was developed based on trauma PI principles to facilitate continued identification of opportunities for improvement despite our decline in trauma admissions. Analysis of the first 18 months of combined ACS PI data is presented. EGS registry inclusion criteria was based on published Association for the Surgery of Trauma's recommendations. Program components and PI categories were based on our existing trauma PI program. Dedicated coordinators actively reviewed and cataloged patient care and outcomes. Deviations from standard practice patterns, unplanned interventions, and other complications were abstracted, categorized, and evaluated through levels of review similar to accepted trauma PI principles. Data for the first six quarters were collated and trends were analyzed. Over 18 months, 696 EGS patients met registry inclusion criteria, with 468 patients (67%) undergoing operative intervention. Over the same time, 353 trauma patients were admitted with 158 undergoing operative intervention (56.4%). Of the 696 EGS patients and 353 trauma patients, 226 (32%) and 243 (69%) PI events were identified, respectively. Common events included unplanned therapies, re-admissions, and unplanned ICU admissions. Based on analysis of all events, four new areas for improvement initiatives were identified. Results of these initiatives included implementation of a multi-disciplinary EGS PI committee, consensus protocols, and departmental and hospital-wide actions. In an 18-month period, integration of our EGS patients into a novel, combined ACS PI program facilitated recognition of an additional 226 PI events and provided a substrate for continued improvements in patient care.

Emergency General Surgery—A Misnomer?

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of nontrauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.

Development of an emergency general surgery process improvement program

BackgroundThe Joint Trauma System has demonstrated improved outcomes through coordinated research and process improvement programs. With fewer combat trauma patients, our military American College of Surgeons level 2 trauma center’s ability to maintain a strong trauma Process Improvement (PI) program has become difficult. As emergency general surgery (EGS) patients are similar to trauma patients, our Trauma and Acute Care Surgery (TACS) service developed an EGS PI program analogous to what is done in trauma. We describe the implementation of our novel EGS PI program and its effect on institutional PI proficiency.MethodsAn EGS registry was developed in 2013. Inclusion criteria were based on AAST published literature. In 2015, EGS registrar and PI coordinator positions were developed and filled with existing trauma staff. A formal EGS PI program began January 1, 2016. Pre- and post-program data was compared to determine the effect including EGS PI events had on increasing yield into our trauma PI program.ResultsIn 2016, TACS saw 1001 EGS consults. Four hundred forty-four met criteria for registry inclusion. Eighty-two patients had 131 PI events; re-admission within 30 days, unplanned therapeutic intervention, and unplanned ICU admission were the most common events. Capture of EGS PI events yielded a 49% increase compared with 2015.ConclusionOverall patient volume and PI events post EGS PI program initiation exceeded those prior to implementation. These data suggest that extending trauma PI principles to EGS may be beneficial in maintaining inter-war military and/or lower volume trauma center readiness.

Adherence to 20 Emergency General Surgery Best Practices: Results of a National Survey.

To examine national adherence to emergency general surgery (EGS) best practices. There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data. A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression. The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries. There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.

Acute care surgery and emergency general surgery: Addition by subtraction.

The formation of Acute Care Surgery services leads to decreased time to treatment and improved outcomes for emergency general surgery (EGS) patients. However, minimal work has focused on the ideal care delivery system and team structure. We hypothesize that the implementation of a dedicated EGS team (separate from trauma and surgical critical care), with EGS-specific protocols and dedicated operating room (OR) time, will increase productivity and improve mortality. This is a retrospective review of financial and EGS registry data from fiscal year (FY) 12 to FY15. Data are from an academic, university-based EGS team composed of two acute care surgery attending surgeons, advanced practitioners (APs), residents, and a fellow. In FY12, processes were implemented to standardize paging of consults, patient sign-out with attending surgeons' and APs' participation, clinical/billing protocols, OR availability, and quality improvement. Outcomes included relative value units (RVUs), surgical case volume, charges/payments, and number of patient encounters. The secondary outcome was mortality. The χ test was used to compare mortality, and p < 0.05 was considered significant. Total patient encounters increased from 6,723 in FY 12 to 9,238 in FY 15 (+37%). Relative value units increased from 18,422 in FY 12 to 25,314 in FY 15 (+37%). Charges increased by 76% and payments increased by 60% from FY 12 to FY 15. Charges per encounter increased from $461 in FY 12 to $591 in FY 15 (+28%) Additionally, both inpatient and surgical case loads increased. Mortality remained stable throughout the study period (FY 12, 4.5%; FY 13, 5.2%; FY 14, 5.3%; FY 15, 3.2%: p = 0.177). Implementation of dedicated OR time, defined EGS team structure, practice protocols, and active attending surgeons'/APs' participation was temporally related to increased case volume, patients seen, and revenue, while mortality remained unchanged. Further study is necessary to establish the translatability of these data to other systems. Economic/decision, level III.

Creation and Implementation of an Emergency General Surgery Registry Modeled after the National Trauma Data Bank

As emergency general surgery (EGS) evolves, an EGS patient-tracking database (EGS registry [EGSR]) similar to the National Trauma Data Bank (NTDB) will be essential to study outcomes and improve care. The goal of this study was to establish diagnostic ICD-9 codes to define EGS patients. The hypothesis was that creating standardized ICD-9-based inclusion criteria would facilitate patient identification for an EGSR and aid in its ongoing development. We conducted a retrospective review of EGS admissions over a 9-month period to define ICD-9 diagnostic codes of patients admitted to our EGS service. Subsequently, prospective data were collected into the EGSR by testing ICD-9-based inclusion criteria over 1 month. Patient, hospital, and severity scoring variables, as well as quality assurance information, were identified. We identified 959 admissions to the EGS service over 9 months with 306 ICD-9 diagnosis codes that define EGS patients; the prospective population of the EGSR confirmed feasibility of ICD-9-based inclusion criteria. The EGSR captures 107 data points and 33 comorbidities per patient over 11 categories, akin to the 10 NTDB categories. Following the model of the NTDB, we have successfully completed creation and initial implementation of an EGSR by using ICD-9-based inclusion criteria. Our comprehensive EGSR creates a prospective data-collection modality to capture and define EGS patients. A uniform patient-tracking EGSR, akin to the NTDB, will advance the science of acute care surgery, improve EGS patient outcomes, and facilitate multi-institutional collaboration.

Does Regionalization of Acute Care Surgery Decrease Mortality?

During the initial development of an Emergency General Surgery (EGS) service, severity of illness (SOI) can be expected to be high and should decrease as the service matures. We hypothesize that a matured regional EGS service would show decreasing mortality and length of stay (LOS) over time. We performed a retrospective study of a prospectively collected EGS registry data from 2004 to 2009. Patients were included if they had been discharged from the EGS service and were stratified by year of discharge. Systemic inflammatory response syndrome, sepsis, shock, peritonitis, perforation, and acute renal failure were used as markers of SOI. Patients were defined as high acuity if they had one or more of these SOI markers. Differences in mortality, LOS, intensive care unit admissions, SOI, charges, and distance were compared across and between years using nonparametric statistical tests (Fisher's exact, Wilcoxon rank-sum, and Kruskal-Wallis tests). A total of 3,439 patients met study criteria. The mean age was 47 years ± 17.5 years. The majority of the patients were female (1,813, 47.3%). The overall LOS was 6.4 days ± 9.4 days (median, 4 days). In all, 2,331 (67.8%) of the patients underwent operation. Over the course of the study period, the SOI indicators stabilized at between 13% and 17% of the patient population with at least one indicator. During that time period, mortality steadily decreased from 4.9% to 1.3% (p < 0.5). Despite consistently high SOI, a dedicated and matured EGS service demonstrated a decrease in mortality and LOS.

Triaging to a Regional Acute Care Surgery Center: Distance Is Critical

In acute care surgery, predicting mortality is important to determine appropriate patient transfer to a regional emergency general surgery (EGS) center. We hypothesized that distance to a referral center and severity of illness (SOI) would be predictors of death. We performed a retrospective analysis of a prospectively collected EGS registry from 2004 to 2008. The study population consisted of all patients discharged from the EGS service with an available home zip code in the registry. Study data included age, gender, length of stay (LOS), intensive care unit (ICU) LOS, distance between our facility and patient home zip code, and need for operative management. Systemic inflammatory response syndrome/sepsis/shock, peritonitis, perforation, and acute renal failure were used as SOI indicators. Mortality at discharge was the primary outcome. Patients were stratified by survival and compared using non-parametric statistical tests. Logistic regression assessed the simultaneous contribution of age, SOI, and distance to risk of death. A total of 3,439 patients met study criteria. Females slightly outnumbered males (1,813, 52.7%) with a median age of 47 years. The overall LOS was 6.4 days±9.3 days, and 2,331 (67.8%) of the patients underwent operation. Mean distance was 41.5 miles±51.2 miles (median, 22.2). Overall mortality was 2.7%. Increasing distance, age, and presence of SOI indicators were associated with mortality in univariable analyses. In multivariable logistic regression controlling for patient age and SOI, increasing distance in miles was related to increased mortality (odds ratio, 1.005; p<0.001). This odds ratio equates to a doubling in odds of death for each 132 miles between our center and the patient's home zip code. Age, SOI, and distance from a regional referral center explain much of the variation in mortality and can be used for triage to regional EGS centers.