Emergency General Surgery Service Research Articles

Demystifying the association of center-level operative trauma volume and outcomes of emergency general surgery

BackgroundRecent studies have demonstrated a positive volume-outcome relationship in emergency general surgery. Some have advocated for the sub-specialization of emergency general surgery independent from trauma. We hypothesized inferior clinical outcomes of emergency general surgery with increasing center-level operative trauma volume, potentially attributable to overall hospital quality. MethodsAdults (≥18 years) undergoing complex emergency general surgery operations (large and small bowel resection, repair of perforated peptic ulcer, lysis of adhesions, laparotomy) were identified in the 2016 to 2020 Nationwide Readmissions Database. Multivariable risk-adjusted models were developed to evaluate the association of treatment at a high-volume trauma center (reference: low-volume trauma center) with clinical and financial outcomes after emergency general surgery. To evaluate hospital quality, mortality among adult hospitalizations for acute myocardial infarction was assessed by hospital trauma volume. ResultsOf an estimated 785,793 patients undergoing a complex emergency general surgery operation, 223,116 (28.4%) were treated at a high-volume trauma center. Treatment at a high-volume trauma center was linked to 1.19 odds of in-hospital mortality (95% confidence interval 1.12–1.27). Although emergency general surgery volume was associated with decreasing predicted risk of mortality, increasing trauma volume was linked to an incremental rise in the odds of mortality after emergency general surgery. Secondary analysis revealed increased mortality for admissions for acute myocardial infarction with greater trauma volume. ConclusionWe note increased mortality for emergency general surgery and acute myocardial infarction in patients receiving treatment at high-volume trauma centers, signifying underlying structural factors to broadly affect quality. Thus, decoupling trauma and emergency general surgery services may not meaningfully improve outcomes for emergency general surgery patients. Our findings have implications for the evolving specialty of emergency general surgery, especially for the safety and continued growth of the acute care surgery model.

Assessment of the quality of care in acute bowel obstruction patients at a tertiary care hospital with the NCEPOD guidelines

Abstract Background Acute bowel obstruction (ABO) is a common cause of admission under the emergency general surgery services offered across the UK. The Aim of this quality improvement project (QIP) was to assess the quality of care for patients with ABO with the national and NCEPOD guidelines in a tertiary care hospital. Method Data was collected for two months in October and November 2022 from an electronic database in the trust and patient notes maintained throughout the admission. Results 35 patients were included in the QIP (19 males and 16 females). Consultant review is recommended in < 14 hours after admission and national statistics show a delay in 15.9% of cases, in our hospital, it was 73.33% (22/30). Pain assessment on admission, the national average is 57% but, in this hospital, it was 42.86% (15/35). Similarly, guidelines recommend assessment of MUST score, hydration status and Rockwood score at admission, which was documented in 0/35, 1/35 and 15/35 cases in our hospital. QIP was presented in the local clinical governance meeting followed by a teaching session to improve the patient care in ABO. Conclusion This QIP showed a lack of documentation in the pain score, hydration status, Rockwood score, MUST score and a delay in the consultant review for patients with ABO when compared with the guidelines of NCEPOD and national statistics. A repeat cycle of this QIP will be conducted in 6 months' time to analyse the effectiveness of the intervention on patient care outcomes.

Common postbariatric surgery emergencies for the acute care surgeon: What you need to know.

The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient. Literature Synthesis and Expert Opinion; Level V.

WTP4.2 Reasons for delays in Emergency General surgery services at Night

Abstract Introduction There are at least 33000 Emergency General Surgery (EGS) cases in the UK annually, with 80-90% of all deaths in general surgery noted in patients undergoing EGS. Delays in undergoing EGS are associated with increased patient morbidity, mortality and increased length of stay. We conducted a study to investigate reasons behind delays in emergency general surgery patients undergoing surgery during the night shift. Methodology Prospective data was collected on all surgical activity in the Emergency theatre after 20:00 hours between 26th February 2022 and 16th April 2022 (50 days). Data was collected from paper medical records. Results 338 patients were booked to undergo surgery during the night shift over the specified time period. 68% (n=230) of cases scheduled for overnight operating had been booked during the day shift (08:00-20:00) whilst 32% (n=108) were booked during the night shift (20:00- 08:00). 70% of cases (n= 236) were rescheduled for surgery the following day. 47% of rescheduled cases were postponed due to surgical decision-making however 31% were postponed due to unavailability of theatre space (Other surgical specialties utilising theatre). All other postponements (22%) were due to anaesthetic team unavailability. Conclusion Our study identifies 3 main reasons for reduced emergency theatre utilisation in the night. Modifiable causes for delay include unavailability of theatre space and anaesthetic team. We recommend dedicated staff and theatre for EGS to improve patient outcomes. We recommend discussion with the on call surgical Consultant prior to postponement for surgical reasons. By improving overnight theatre utilisation, hospital pressures and patient outcomes stand to be improved.

ThTP8.10 Creating a Team Culture of Building a reliable NELA Database in a District General Hospital

Abstract Introduction In St Helier Hospital, Surrey, we run a busy Emergency General Surgery Service, performing almost 200 laparotomies annually. It is remarkable that in our Department every laparotomy case is consultant-led and that the percentage of HDU admission of high perioperative risk cases reaches 100%, leading to survival rates that are above the UK average. However, the NELA database has not been updated consistently with cases missing and others entered erroneously. As a result, the NELA database does not reliably reflect the quality of care we provide to our patients and undermines the Department’s CQC metrics. Methods We established a multidisciplinary QI Project involving the Departments of General Surgery, Anaesthetics and Intensive Care to create a team culture of commitment to NELA collection data. Interventions Results Conclusion Simple measures as well as raising awareness among the implicated professionals has led to great improvement in adherence to updating NELA database.

Characteristics of emergency general surgery services in Switzerland: a nationwide survey

ObjectiveRunning an emergency general surgery (EGS) service is challenging and requires significant personnel and institutional resources. The aim of this study was to achieve a nationwide overview of the individual EGS service organizations in public hospitals in Switzerland.MethodsAll Swiss public hospitals with a surgical and emergency department were included and contacted by telephone. General surgeons were interviewed between December 2021 and January 2022 using a standardized questionnaire.ResultsSeventy-two out of 79 public hospitals in Switzerland (91.1%) agreed to the survey. They employed 1,581 surgeons in 19 (26.4%) hospitals with < 100 beds, 39 (54.2%) hospitals with 100–300 beds, 7 (9.7%) with 300–600 beds, and 7 (9.7%) with > 600 beds. The median number of surgeons per hospital was 20.5 (IQR 13.0–29.0). Higher level of care (intermediate or intensive care unit) was significantly less available in small hospitals (< 100 beds). The median hour of designated emergency operating room capacity per day was 14 h (IQR 14–24) for all hospitals with < 600 beds and 24 h (IQR 14–24) for the largest hospitals (> 600 beds). With increasing hospital size, there was a significant increase in the number of surgical units where EGS and orthopedic trauma surgery were covered by two separate teams (21.1% vs. 43.6% vs. 85.7% vs. 100%, p = 0.035). The median number of surgeons on-call per hospital and per 24 h was 5.0 (IQR 3.3–6.0).ConclusionLack of higher level of care in small hospitals, limited emergency OR capacity and short rotations of on-call teams are major drawbacks of many current EGS systems in Switzerland. Centralization of critically ill EGS patients and reorganization of surgical on-call systems to designated acute care surgery teams should be considered.

Standardized Approach to Managing Adhesive Small Bowel Obstructions Reduces Hospital Length of Stay on the Emergency General Surgery Service

Standardized Approach to Managing Adhesive Small Bowel Obstructions Reduces Hospital Length of Stay on the Emergency General Surgery Service

Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project

BackgroundFor patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. MethodsA resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. ResultsThe frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. ConclusionAlthough a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

Outcomes of Small Bowel Obstructions by Admitting Specialty and Hospital Type.

Small bowel obstructions (SBOs) account for a significant burden on the health care system. Should the ongoing trend of regionalizing medicine extend to these patients? We investigated if there is a benefit to admitting SBOs to larger teaching hospitals and to surgical services. We performed a retrospective chart review of 505 patients admitted to a Sentara Facility between 2012 and 2019 with a diagnosis of SBO. Patients between the ages of 18 and 89 were included. Patients were excluded if they required emergent operation. Outcomes were evaluated based on patient's admission either to a teaching or community hospital as well as the admitting service's specialty. Of 505 patients admitted with a SBO, 351 (69.5%) were admitted to a teaching hospital. 392 (77.6%) patients were admitted to a surgical service. The average length of stay (LOS) (4 vs 7days, P < .0001) and cost ($18,069.79 vs $26,458.20, P < .0001) were lower at teaching hospitals. The same trends in LOS (4 vs 7days, P < .0001) and cost ($18,265.10 vs $29944.82, P < .0001) were seen with surgical services. The 30-day readmission rate was higher in teaching hospitals (18.2% vs 11%, P = .0429), and no difference was seen in operative rate or mortality. These data would suggest that there is a benefit to admitting SBO patients to larger teaching hospitals and to surgical services with regard to LOS and cost, suggesting that these patients might benefit from treatment at centers with emergency general surgery (EGS) Services.

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement.

Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients. We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP. Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001). Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams. Therapeutic/Care Management; Level IV.

Spatial access to Emergency General Surgery (EGS) services and EGS bypass behaviours in California

ABSTRACT Hospital bypass behaviours (i.e. people go to faraway hospitals instead of close ones) of Emergency General Surgery (EGS) patients may cause treatment delays and worsened health outcomes. This study aimed to find the associations between EGS bypass behaviours and spatial access to EGS services as well as other factors at the individual level and ZIP Code Tabulation Area (ZCTA) level in California. We used a gravity model to calculate spatial access to EGS services at the ZCTA level. A Bayesian hierarchical spatial model was used to access associated variables of EGS bypass while accounting for spatial autocorrelation. Results show that better spatial access to EGS hospitals was associated with lower likelihood of EGS bypass. Other factors such as rural–urban status, health insurance type and race/ethnicity were also related to EGS bypass behaviours. Besides, people with similar EGS bypass behaviours seemed to cluster together due to spatial effect. Our results have important implications for EGS resource allocation, utilization and EGS disparity alleviation.

Evaluating a pilot, structured, face-to-face, antimicrobial stewardship, prospective audit-and-feedback program in emergency general surgery service in a community hospital.

Prospective audit and feedback (PAF) is an established practice in critical care settings but not in surgical populations. We pilot-tested a structured face-to-face PAF program for our acute-care surgery (ACS) service. This was a mixed-methods study. For the quantitative analysis, the structured PAF period was from August 1, 2017, to April 30, 2019. The ad hoc PAF period was from May 1, 2019, to January 31, 2021. Interrupted time-series segmented negative binomial regression analysis was used to evaluate change in antimicrobial usage measured in days of therapy per 1,000 patient days for all systemic and targeted antimicrobials. Secondary outcomes included C. difficile infections, length of stay and readmission within 30 days. Each secondary outcome was analyzed using a logistic regression or negative binomial regression model. For the qualitative analyses, all ACS surgeons and trainees from November 23, 2015, to April 30, 2019, were invited to participate in an email-based anonymous survey developed using implementation science principles. Responses were measured using counts. In total, 776 ACS patients were included in the structured PAF period and 783 patients were included in the in ad hoc PAF period. No significant changes in level or trend for antimicrobial usage were detected for all and targeted antimicrobials. Similarly, no significant differences were detected for secondary outcomes. The survey response rate was 25% (n = 10). Moreover, 50% agreed that PAF provided them with skills to use antimicrobials more judiciously, and 80% agreed that PAF improved the quality of antimicrobial treatment for their patients. Structured PAF showed clinical outcomes similar to ad hoc PAF. Structured PAF was well received and was perceived as beneficial by surgical staff.

EGS P20 Emergency General Surgery – A state of the nation survey

Abstract Background ERAS (enhanced recovery after surgery) programmes have delivered improved outcomes across the elective surgery landscape but emergency surgery has historically lagged behind with its improvements. The introduction of acute care surgery principles in the United States and projects such as NELA (National Emergency Laparotomy Audit) in the United Kingdom are working to change this. Despite the improvement in outcomes seen by NELA there lacks clarity over the structure and provision of services across the UK. No study to date has examined how Emergency General Surgery care is currently organised and therefore how these organisational structures are changing as new innovations to patient care are delivered. This study aims to ascertain the current organisation structures of emergency surgical care within England and whether there are plans for this to change. Methods A survey was defined and sent to hospitals across England via Freedom of Information (FOI) Requests. Trusts were identified from the online NHS Service Directory and cross referenced with the NELA list of participating hospitals. This led to FOIs sent to 123 acute Trusts in England. Responses not received within 8 weeks were not included in the study. Questions were identified and wording agreed by the authors. Trusts were asked their current working structure and whether they have plans to change within the next five years. Organisational structures were categorised as A; Mixed general surgical take under a non-specific general surgery consultant, B; Daily allocation of acute admission to a general surgery subspecialty (Upper GI / Colorectal / Hepatobiliary), C; Dedicated Emergency General Surgery consultants / service during weekdays only (Monday to Thursday, or Monday to Friday), D; Dedicated Emergency General Surgery consultants / service weekdays and weekends, or E; Other. Results 101 out of 124 trusts responded within the 8-week timeframe. 3 trusts declined to supply information on organisational structure. The remaining reported organisational structures of A; n=36, B; n= 16, C; n=10, D; n=30, E; n=5. In total 41.24% of hospitals reported having an active EGS service in place. Mean bed numbers across different organisational types were Group A; 617.62, Group B; 867, Group C; 648, Group D; 559.5, Group E; 800.71. Mean admissions were Group A; 3983.08, Group B; 6088.29, Group C; 4432.14, Group D; 4123.52, Group E; 4578. Mean NELA cases were Group A; 134.29, Group B; 187, Group C; 164, Group D; 142.11, Group E; 187.17. Regarding number of consultants in place to run an EGS service group C reported a range of 2 to 14 consultants, with a mean of 6. Group D reported a range of 3 to 13 consultants, with a mean of 8.14. Regarding plans to move towards an EGS service group A reported Yes; 9 (25%), No; 22 (61.11%), TBD; 2 (5.56%), no answer given; 3 (8.33%). Group B reported Yes; 3 (18.75%), No; 10 (62.5%), TBD; 3 (18.75%). Conclusions The speciality of Emergency General Surgery (EGS) within the United Kingdom is expanding with annual EGS symposiums being held by professional bodies such as ASGBI, EGS trainee groups forming such as the Moynihan Academy, and large institutions altering their service specifically towards hiring consultants in EGS positions. This follows the Royal College's Acute and Emergency Care joint position statement, the consensus statement from ASGBI and the Getting It Right First Time (GIRFT) emergency surgery report which explicitly state that a dedicated surgical assessment unit, with senior surgeon directing patient throughput has been shown to reduce costs and increase effectiveness of a surgical department. This study shows that 41.24% of trusts in England deliver an EGS service but in heterogenous structured formats. What is clear is that a dedicated EGS service is becoming more popular, with 25% of group A services, and 18.75% of group B services reporting active plans in the next 5 years to create this service. This further impresses the need for categorisation of service provision types, and the sharing of information, to ensure that England does not end with a patchwork of service types confusing patients and rotating clinical practitioners alike.

Impact of Interfacility Patient Transport for Appendectomy on Patient Outcomes

<h3>Introduction</h3> Patients presenting to emergency departments with complaints requiring emergency general surgery (EGS) often require transport to tertiary care because fewer than 50% of hospitals have EGS services. The need for interfacility transport to tertiary care is associated with increased hospital length of stay (LOS) and morbidity among medical patients, however there is limited data available evaluating the cost and impact of transports among EGS patients. The purpose of this study was to analyze the costs, transport resource utilization, and outcomes of EGS patients transferred to tertiary care with acute appendicitis. <h3>Methods</h3> This was an IRB approved retrospective study of adult patients transferred from an in-network referral ED to a single tertiary care facility between 20 May 2015 & 30 September 2020 who were transferred with diagnosis of appendicitis. Data collected from the health system's electronic medical record (EMR) included patient demographics, emergency department and interfacility transport hemodynamics, diagnostic testing results, timeliness of referral and transport, transport level of care, social determinants of health, and patient charges. Data was analyzed with R version 1.0.2. Our Primary Outcome was the hospital length of stay and our secondary outcomes were time from initial presentation to incision, cost to patient, and transport resource allocation. <h3>Results</h3> A total of 480 adult patients were transferred for tertiary EGS care during the study period and were included in the final analysis. 89.4% of patients (n=429) received ambulance transport awhile 10.6% (n=51) were transported via private vehicle. All patients were discharged home alive. Critical Care Transport (CCT) teams transported 61.5% (n=295) of patients while Advanced Life Support (ALS) teams transported 26.0% (n=125). Although CCT teams were more likely than ALS teams to establish and maintain intravenous fluids (54.6% vs 37.6%, p=0.002) there was no difference in analgesia (36.9% vs 27.4% p=0.078), antiemetic (26.8% vs 20.0% p=0.178), or antibiotic (13.3% vs 6.4% p=0.062) administration between critical care and ALS providers. No life-saving interventions were provided by any transport team. Ambulance transport did not shorten hospital length of stay compared to transport via private vehicle (p=0.67). <h3>Conclusion</h3> In this single center study transport via ambulance did not reduce hospital length of stay compared to transport via private vehicle and there was no difference in the care provided between ALS and CCT teams.

The Influence of Social Determinants of Health on The Interfacility Transport of Patients for Appendicitis

<h3>Introduction</h3> Patients presenting to emergency departments with complaints requiring emergency general surgery (EGS) often require transport to tertiary care because fewer than 50% of hospitals have EGS services. The need for interfacility transport to tertiary care is associated with increased hospital length of stay (LOS) and morbidity among medical patients. Further Social Determinants of Health (SDOH) are known factors worsening patient outcomes. There is limited data available evaluating the presence and influence of SDOH among EGS patients transferred to tertiary care. The purpose of this study was to analyze the costs, transport resource utilization, and outcomes of EGS patients transferred to tertiary care with acute appendicitis. <h3>Methods</h3> This was an IRB approved retrospective study of adult patients transferred from an in-network referral ED to a single tertiary care facility between 20 May 2015 & 30 September 2020 who were transferred with diagnosis of appendicitis. Data collected from the health system's electronic medical record (EMR) included patient demographics, emergency department and interfacility transport hemodynamics, diagnostic testing results, timeliness of referral and transport, transport level of care, social determinants of health, and patient charges. Data was analyzed with R version 1.0.2. Our Primary Outcome was the hospital length of stay and our secondary outcomes were time from initial presentation to incision, cost to patient, and transport resource allocation. <h3>Results</h3> A total of 480 adult patients were transferred for tertiary EGS care during the study period and were included in the final analysis. 89.4% of patients (n=429) received ambulance transport awhile 10.6% (n=51) were transported via private vehicle. All patients were discharged home alive. SDOH were documented as present in 25.5% of patients transported via private vehicle and 30.8% of patients transferred via ambulance. The presence of SDOH did not length emergency department length of stay (p=0.12) or hospital length of stay (p=0.45). SDOH did not impact hospital length of stay when transport mode was also considered (p=0.447) <h3>Conclusion</h3> In this single center study, the presence of SDOH did not influence ED or hospital length of stay among patients transferred to tertiary care for appendectomy. Overall SDOH were poorly reported in the hospital and ambulance electronic medical record. Improved tracking of these social factors may alter the results of future research.

Resident-Led Effort Improves Adoption of Advance Care Planning among Emergency General Surgery Patients

INTRODUCTION: Advanced Care Planning (ACP) is underused in surgery, especially among older adults undergoing high-risk operations. For patients who may permanently or temporarily lose their ability to communicate preferences, pre-operative ACP and identification of a surrogate decision-maker is often the only mechanism to guide medical decision-making. METHODS: A resident-led, collaborative (faculty, advanced practice providers [APP], medical student, and nurse) quality improvement project including education (grand rounds, case-based conferences, didactic sessions), performance measurement and financial incentives, conducted on the Emergency General Surgery (EGS) service aimed to increase use of a tailored surgical template in the ACP tab in the electronic health record (EHR). 566 patients in the baseline period (2020-2021) were compared to 423 patients in the project period (2021-2022). Residents were surveyed about barriers to adoption. RESULTS: ACP compliance increased by 8.1% (10.1% to 18.2%) with a greater increase noted in patients age 65+ (20.3% vs 34.3%). Residents and APPs completed ACP, usually by integrating into patient admission workflow (52.1% within the first 24 hours of admission). For major cases, ACP compliance rates increased by 19.7% (18.9% to 38.6%). Residents surveyed (n = 19), all of whom had an ACP conversation all recognized the importance of ACP, noted barriers, including competing clinical duties (50%), patient or family hesitancy (30%), and language barriers (15%), (Table 1). CONCLUSION: A resident-APP partnership was effective at increasing ACP adoption on an EGS service. Further study is needed to identify approaches to facilitate ACP conversations in EGS patients with limited English proficiency.Table 1

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

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

TU8.11 Improving the efficiency of the EGS service in a University Teaching Hospital. Smarter application of standards and use of resources

Abstract Aim Effective utilization of resources for emergency general surgery (EGS) is essential for operational efficiency. Many patients have pathology with a time-dependent outcome and clinical standards have been established regarding timing of surgical intervention. The aim of this study was to investigate barriers to the delivery of timely EGS. Methods The delivery of EGS between 31/01/21 and 30/08/21 was studied. All cases were reviewed to determine clinical urgency, appropriateness of “urgency” within the clinical context (diagnosis, NEWS-2 score) and timing of EGS. Discrepancies between theatre booking and clinical need and delay in undertaking EGS compared with the relevant clinical standards were identified. Results EGS was undertaken in 520 patients (262M:258 F), mean age 49 (16–101) years. 34(6%) were booked as needing “immediate”, 130 (25%) “urgent 2–6hr”, 242 (47%) “urgent 6–18 hr” and 114 (22%) “expedited” EGS. In 373 (71.7%), EGS was undertaken in a time frame which met (or exceeded) relevant standards. In 235 (45%) cases, the urgency of booking exaggerated clinical need. EGS was “delayed” in 147 (28.3%) cases when compared with urgency as booked, but when actual clinical need was reviewed EGS was delayed in only 66 cases (12.7%). Delay was due to unavailability of facilities in 25 (38%) of cases, whereas in 24 (36%) treatment was delayed purely “overnight”. Conclusion Inappropriate allocation of clinical urgency resulted in the majority of “delayed” EGS. The routine application of RCS18 standards would prevent this. Avoiding delay overnight and an increase in theatre resource would improve efficiency.

TH6.8 The Utility and Impact of Advanced Nurse Practitioners in Unplanned Surgical Admissions: A Review of the Literature

Abstract Aims Advanced Nurse Practitioners (ANP) are well established within acute medical and Critical Care environments. The evolution of surgical ANPs have tended towards preoperative roles, such as anaesthesia or scrub, with few clinical roles involving the assessment of acute patients or inpatient care. The Royal College of Surgeons of England have recently recognised, by professional membership, the roles of non-medical members of the surgical team, such as ANPs and physician associates. This review explores the areas of impact of ANPs on the emergency General Surgery service provision to help develop the role of the modern surgical ANP. Methods A scoping literature review was performed to identify themes of ANP function and outcome. Search terms such as “Advanced Nurse Practitioners”, “Surgical Assessment Units” and “outcomes” were combined with Boolean operators to query PubMed, BNI, CINAHL, Google Scholar and HMIC databases. Studies in the last decade were included. Results We identified and screened 54 unique articles. 40 articles were reviewed for eligibility and 21 were included in this review. A thematic analysis identified the impact of ANPs on the process of care (such as assessment and treatment waiting times and patient satisfaction) and outcomes of care (readmission rates, length of stay and cost-effectiveness). Conclusion Research into the impact of ANPs are largely focused on objective outcome measures and within non-surgical specialties. Whilst this review demonstrates the positive aspects of ANP care on emergency care, we identify a paucity of evidence on patient-focused outcomes and the impact of ANPs on the patient journey within surgery.

EP-604 The Golden Patient Pathway - Improving Efficiency of Emergency General Surgery Theatres and Bed Management

Abstract Aim This closed loop audit aimed at improving efficiency of time management with good utilisation of the first hour of the day in emergency theatres. This was reflected on bed management and patient service. Methods Patients who required simple emergency operations were the target population. Retrospective data of patients’ demographics, time of attendance to surgical admission unit, time waiting for an operation, anaesthetic start times, surgical start times and postoperative inpatient stay were collected. Then the Golden patient pathway was implemented via a list of agreed criteria for the Golden patient (simple procedure, non-septic, non-diabetic, etc.). The chosen patient was labelled as Golden on the booking form. A precise time scale for anaesthetic review and theatre sending time was agreed. This pathway was tried for a month followed by data collection to compare outcomes. Results After starting the Golden patient pathway in our emergency surgery service, the mean anaesthetic start time (+/- standard deviation) improved from 09:12 +/- 0.11 to 08:32 +/- 0.01. Consequently, the mean operation start time improved from 09:45 +/- 0.10 to 08:53 +/- 0.01. The percentage of patients with same day discharge after simple procedures increased from 57% to 100% thus providing better use of hospital beds. Conclusion The Golden patient pathway provides a good utilisation of the first hour of the day in emergency theatres. It has a positive impact on patient service and bed management via reducing the waiting times. The Golden patient pathway is an asset to the emergency general surgery service.