Patients Undergoing Emergency General Surgery Research Articles

SP9.5 - Peri-operative Comprehensive Geriatric Assessment (CGA): A new benchmark for Acute General Surgery patients

Abstract Aims More than 50% of patients undergoing emergency general surgery are over 65 years of age. NICE guidelines emphasise frailty assessment in acute surgical settings, particularly in the preoperative period. Similarly, the Emergency Laparotomy and Frailty (ELF) study showed associations between frailty (CFS ≥ 5) and 90-day mortality, increased complication and length of hospital stay in older emergency laparotomy patients. NELA best practice tariff (BPT) April 2023 heavily focuses on perioperative team involvement in frailer, older patients. This is an audit from a city teaching hospital, with a surgical liaison team against standards set by NELA. Methods Review of patients aged ≥ 65 undergoing emergency laparotomies between August and November 2023 (pre-intervention) then December and January 2024 (post-intervention). Data collected includes whether patients had a documented frailty score, a clearly documented CPR decision & treatment escalation plan (TEP), pre- or post-operative medical review, and advanced-care planning (ACP) post-operatively. Intervention included dedicated members of surgical liaison team following patients throughout admission, weekly meetings to discuss laparotomy patients, older patient template being created capturing ceilings of care, frailty score, and social history. Results Post intervention, improvement in clear documentation regarding escalation, frailty level. Greater level of MDT collaboration with regards to older patients undergoing laparotomies. Conclusion Changes in NELA BPT emphasise the importance of comprehensive geriatric assessment in the management of older laparotomy patients. Even a basic surgical liaison service can achieve high levels of compliance with a few simple strategies, resulting in better outcomes for patients as well as financial benefits for Trusts.

Racial and Ethnic Disparities in Emergency General Surgery Outcomes Among Older Adult Patients

IntroductionRacial and ethnic disparities in emergency general surgery (EGS) patients have been well described in the literature. Nonetheless, the burden of these disparities, specifically within the more vulnerable older adult population, is relatively unknown. This study aims to investigate racial and ethnic disparities in clinical outcomes among older adult patients undergoing EGS. MethodsThis retrospective analysis used data from 2013 to 2019 American College of Surgeons National Surgery Quality Improvement Program database. EGS patients aged 65 y or older were included. Patients were categorized based on their self-reported race and ethnicity. The primary outcomes evaluated were in-hospital mortality, 30-d mortality, and overall morbidity. Multivariable logistic regression was performed to examine the relationship between race/ethnicity and postoperative outcomes while adjusting for relevant factors including age, comorbidities, functional status, preoperative conditions, and surgical procedure. ResultsA total of 54,132 patients were included, of whom 79.8% identified as non-Hispanic White, 9.5% as non-Hispanic Black (NHB), 5.8% as Hispanic, and 4.2% as non-Hispanic Asian. After risk adjustment, compared to non-Hispanic White patients, NHB, non-Hispanic Asian, and Hispanic patients had decreased odds of 30-d mortality. For 30-d readmission and reoperation, differences among groups were comparable. However, NHB patients had significantly increased odds of overall morbidity (adjusted odds ratio, 1.18; 95% confidence interval: 1.10-1.26; P < 0.001) and postoperative complications including sepsis, venous thromboembolism, and unplanned intubation. Hispanic ethnicity was associated with lower odds of postoperative myocardial infarction and stroke. ConclusionsAmong older adult patients undergoing emergency general surgery, minority patients experienced higher morbidity rates, but paradoxical disparities in mortality were detected. Further research is necessary to identify the cause of these disparities and develop targeted interventions to eliminate them.

Impact of Procedure Risk vs Frailty on Outcomes of Elderly Patients Undergoing Emergency General Surgery: Results of a National Analysis.

The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty. Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes. A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty. Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.

2349 How to provide a cost-effective geriatric peri-operative service within general surgery in line with NELA BPT

Abstract Introduction More than 50% of patients undergoing emergency general surgery are &amp;gt;65 years. The Emergency Laparotomy and Frailty (ELF) study showed strong associations between frailty (CFS ≥ 5) and increased mortality, risks of complications, and length of hospital stay. Methods For nearly 10 years, we have had geriatric liaison input for general surgery and colorectal patients in a tertiary teaching centre. This has transformed into a fully embedded service involving consultant geriatrician, registrars and senior house offices, providing 3-day a week medical input. NELA best practice tariff (BPT) April 2023 emphasises perioperative Geriatric team involvement in frail patients aged 65 and above. The main metrics include CFS, an MDT-based risk assessment, treatment escalation decision making and perioperative geriatrician involvement. Results The service has previously demonstrated significant improvement in patient care and holistic management including reducing the length of stay in hospital (average decrease of 5.5 days). Simple job planning, use of current resources and efficiency can mean Trusts can incorporate geriatricians with essential skills to improve patient management and reach NELA BPT. Conclusion Changes in NELA BPT emphasise the importance of comprehensive geriatric assessment in the management of older laparotomy patients. Introducing a multidisciplinary geriatric liaison service into the general surgical department can achieve high levels of compliance with national guidelines, resulting in better outcomes for patients as well as financial benefits for Trusts. This is particularly pertinent given the financial constraints on many services across the NHS, this is an opportunity to increase revenue and build a geriatric workforce.

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

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

National trends and outcomes of robotic emergency general surgery in the United States

BackgroundRobot-assisted surgery has seen exponential adoption over the last decade. Although the safety and efficacy of robotic surgery in the elective setting have been demonstrated, data regarding robotic emergency general surgery remains sparse. MethodsAll adults undergoing non-elective appendectomy, cholecystectomy, small or large bowel resection, perforated ulcer repair, or lysis of adhesions were identified in the 2008 to 2020 National Inpatient Sample. Temporal trends were analyzed using a rank-based, non-parametric test developed by Cuzick (nptrend). Using laparoscopy as a reference, multivariable regressions were used to evaluate the association between robotic techniques and in-hospital mortality, major complications, and resource use for each emergency general surgery operation. ResultsOf an estimated 4,040,555 patients undergoing emergency general surgery, 65,853 (1.6%) were performed using robotic techniques. The robotic proportion of minimally invasive emergency general surgery increased significantly overall, with the largest growth seen in robot-assisted large bowel resections and perforated ulcer repairs. After adjustment for various patient and hospital-level factors, robot-assisted large bowel resection (adjusted odds ratio 0.73, 95% confidence interval 0.58–0.91) and cholecystectomy (adjusted odds ratio 0.66, 95% confidence interval 0.55–0.81) were associated with significantly reduced odds of perioperative blood transfusion compared to traditional laparoscopy. Although robotic techniques were associated with modest reductions in postoperative length of stay, costs were uniformly higher by increments of up to $4,900. ConclusionRobotic surgery appears to be a safe and effective adjunct to laparoscopy in minimally invasive emergency general surgery, although comparable cost-effectiveness has yet to be realized. Increasing use of robotic techniques in emergency general surgery may be attributable in part to reduced complications, including blood loss, in certain operative contexts.

Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis.

Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort. All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest. Of ∼1653169 patients, 107945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (β + 1.04days, CI + .91-1.17) and greater costs (β+$3,490, CI + 2840-4140). While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Incidence and outcomes of emergency department patients requiring emergency general surgery: a 5-year retrospective cohort study.

Patients undergoing emergency general surgery are at high risk of complications and death. Our objectives were to estimate the incidence of emergency general surgery in a Swiss University Hospital, to describe the characteristics and outcomes of patients undergoing such procedures, and to study the impact of age on clinical outcomes. This was a retrospective cohort study of adult patients who visited the emergency department (ED) of Geneva University Hospitals between January 2015 and December 2019. Routinely collected data were extracted from electronic medical records. The primary outcome was the incidence of emergency general surgery among patients visiting the emergency department, defined as general surgery within three days of emergency department admission. We also assessed demographic characteristics, mortality, intensive care unit admission and patient disposition. Multivariable log-binomial regression was used to study the associations of age with intensive care unit (ICU) admission, one-year mortality and dependence at discharge. Age was modelled as a continuous variable using restricted cubic splines and we compared older patients (75thpercentile) with younger patients (25thpercentile). Between January 2015 and December 2019, a total of 310,914 emergency department visits met our inclusion criteria. Among them, 3592 patients underwent emergency general surgery within 3 days of emergency department admission, yielding an annual incidence of 116 events per 10,000 emergency department visits (95% CI: 112-119), with a higher incidence in females and young patients. Overall, 5.3% of patients were admitted to ICU, 7.8% were dependent on rehabilitation or assisted living at discharge and 4.8% were dead after one year. Older patients had a higher risk of ICU admission (adjusted risk ratio (aRR) 2.9 [1.5-5.4]), dependence at discharge (aRR 15.3 [5.5-42.4]) and one-year mortality (aRR 5.4 [2.2-13.4]). Emergency department visits resulting in emergency general surgery are frequent, but their incidence decreases with patient age. Mortality, ICU admission and dependence at discharge following emergency general surgery are more frequent in older patients. Taking into account the increased risk for older patients, a shared process is appropriate for making more informed decisions about their options for care.

Unplanned Returns to Theatres in Emergency General Surgery; What can be improved?

Abstract Introduction Unplanned return to theatre impacts physical, psychological, social and financial aspects of patients and healthcare. It is a significant adverse event, which can be avoided, nonetheless reduced. This study aims to review the incidence of unplanned return to theatre in Emergency General Surgery at a District General Hospital. Methods A retrospective review of patients undergoing Emergency General Surgery between January 2019 to January 2021 was done. Data was obtained from the hospital management information systems. The operations were classified based on primary operation, followed by indication for the return. Results A total number of 1578 patients underwent emergency general surgery operations over a period of 25 months (Jan 2019-Jan 2021). The unplanned return to theatres (URTT) were 85 (5.3%), with a 90-day mortality of 16. There were 12 (14.11%) appendicectomies, 7 (8.2%) necrotizing fasciitis, 25 (29.4%) abscess, 5 (5.8%) hernias, 16 (18.8%) large bowel, 19 (22.3%) small bowel operations and 1 (1.17%) laparoscopic cholecystectomy. The total number of appendicectomies were 302 with 3.9% (12) URTT. Similarly, 4.2% (n=583) abscesses, 22.8% (n=70) large bowel operations, 6% (n=316) small bowel operations were returned. 66% of the abscesses were returned for redo/debridement. Conclusion Unplanned returns to theatres pose a major burden to the healthcare system. There is no established data for an acceptable rate of URTT in emergency general surgery. Most of the returns in our study, are due to haemorrhage or inadequate drainage of the abscess, both of these complications could easily be prevented with meticulous surgical technique.

70 Decision to Incision Time: Can the Principle Be Applied to Emergency General Surgery in Order to Tackle Delays in Patient Care?

Abstract Aim General surgical patients who require emergency surgery should have timely access to operating theatre to ensure optimal outcomes. It is important to evaluate delays in order to identify contributing elements and help to improve standards of surgical care. The decision to incision time interval is a benchmark used in obstetric practice. This study aimed to assess the use of this time interval in the emergency general surgical setting to consider whether the principle may be translatable. Method Prospective data were collected on patients undergoing emergency general surgery in a tertiary care centre over four weeks. Data were extracted from patient notes and anonymised for statistical analysis. Results No statistically significant associations were found with the studied variables and decision to incision time. However, this study identified clear delays, with 66% of emergency operations taking place after target time assigned by NCEPOD classification. It identified trends in varying decision to incision time in patient and procedure type. It also identified issues with documentation and an association between longer decision to incision time and post-operative length of stay. Conclusions This study highlights important delays in emergency general surgery. Decision to incision time reveals important trends and, with larger sample sizes, may identify areas which hinder time-sensitive procedures. This study recommends that decision time could be more formally incorporated into surgical documentation to better monitor delays. The findings of this study could inform future research, which is required to determine the true potential of using decision to incision time interval in emergency general surgery.

351 A Service Evaluation of Emergency Laparotomy and Total Parenteral Nutrition at a Single Teaching Hospital

Abstract Aim Malnourished patients undergoing emergency general surgery (EGS) have a greater risk of mortality than those not malnourished. There is often a need for nutritional support in EGS. This study investigated the risk factors for total parenteral nutrition (TPN) in patients undergoing emergency laparotomy, and whether there is an association with the NELA risk score. Method A five-year review (June 2016-2021) of the local NELA database and referrals to the Nutrition Support Team was performed. Pre-operative, operative and post-operative data for patients who received TPN and those who did not was collected. Associations between risk factors including NELA score and TPN use were examined using chi squared test and Mann Whitney U, as appropriate. Results There were 931 NELA patients, of which 22.8% (n = 173) received TPN. Intestinal obstruction was the commonest indication for surgery at 51.3% (n = 478) with no difference in age or sex. Despite patients receiving TPN being more likely to be frail (0.004), have higher ASA scores (0.001), lower albumin levels (&amp;lt;0.001), and worse pre- and post-operative NELA scores (both 0.002), stoma formation (0.002) and mortality (&amp;lt;0.001) was half that in patients without TPN. Sub-analysis reveals this was irrespective of when TPN was administered. Conclusions Two mutually exclusive explanations exist. TPN may be a predictor of disease severity and subsequent clinical intervention, or it may indeed improve the nutritional and clinical outcomes in this high risk EGS group. Further studies are needed to clarify this, in addition to the most appropriate method of identifying malnutrition in NELA-eligible patients.

Analysis of Variables Influencing Short-Term Complications in Geriatric Patients Undergoing Emergency General Surgery (EGS): A Retrospective Cohort Study.

Emergency general surgery (EGS) encompasses a wide range of acute surgical conditions that pose significant risks to patient life and well-being. Understanding the factors that contribute to short-term complications in geriatric patients undergoing EGS is crucial for improving patient outcomes. This retrospective single-center cohort study aimed to evaluate the impact of various variables on short-term complications in geriatric patients undergoing EGS. A total of 212 patients aged 65 and above who underwent emergency abdominal surgery between 2017 and 2018 were included in the study. The analysis focused on several variables, including age, sex, body mass index (BMI), beta-blocker use, open abdomen treatment, blood transfusions, anticoagulant therapy, and vasopressor use. Univariate and multivariate analyses were conducted to assess the association between these variables and short-term complications. Among the analyzed variables, blood transfusionsand vasopressor use demonstrated a statistically significant association with short-term complications. Patients who received blood transfusions had a significantly higher risk of complications, with an odds ratio (OR) of 3.01 (95% confidence interval, CI: 1.28-7.06, p-value = 0.011). Similarly, the use of vasopressors was strongly correlated with increased short-term complications, with an OR of 14.61 (95% CI: 4.86-43.89, p-value < 0.001). These findings emphasize the importance of minimizing blood transfusions and careful consideration of vasopressor use in geriatric patients undergoing EGS to reduce the risk of short-term complications. Further research is warranted to explore additional factors and optimize perioperative management strategies to improve outcomes in this vulnerable patient population.

WTP4.3 A Service Evaluation of Emergency Laparotomy and Total Parenteral Nutrition at a Single Teaching Hospital

Abstract Aims Malnourished patients undergoing emergency general surgery (EGS) have a greater risk of mortality than those not malnourished. There is often a need for nutritional support in EGS. This study investigated the risk factors for total parenteral nutrition (TPN) in patients undergoing emergency laparotomy, and whether there is an association with the NELA risk score. Methods A five-year review (June 2016-2021) of the local NELA database and referrals to the Nutrition Support Team was performed. Pre-operative, operative and post-operative data for patients who received TPN and those who did not was collected. Associations between risk factors including NELA score and TPN use were examined using chi squared test and Mann Whitney U, as appropriate. Results There were 931 NELA patients, of which 22.8% (n=173) received TPN. Intestinal obstruction was the commonest indication for surgery at 51.3% (n=478) with no difference in age or sex. Despite patients receiving TPN being more likely to be frail (0.004), have higher ASA scores (0.001), lower albumin levels (&amp;lt;0.001), and worse pre- and post-operative NELA scores (both 0.002), stoma formation (0.002) and mortality (&amp;lt;0.001) was half that in patients without TPN. Sub-analysis reveals this was irrespective of when TPN was administered. Conclusions Two mutually exclusive explanations exist. TPN may be a predictor of disease severity and subsequent clinical intervention, or it may indeed improve the nutritional and clinical outcomes in this high risk EGS group. Further studies are needed to clarify this, in addition to the most appropriate method of identifying malnutrition in NELA-eligible patients.

ThTP5.6 Decision to Incision Time: Can the principle be applied to emergency general surgery in order to tackle delays in patient care?

Abstract Introduction General surgical patients who require emergency surgery should have timely access to operating theatre to ensure optimal outcomes. It is important to evaluate delays to identify contributing elements and help to improve standards of surgical care. The decision to incision time interval is a benchmark used in obstetric practice. This study aimed to assess the use of this time interval in the emergency general surgical setting to consider whether the principle may be translatable. Methods Prospective data were collected on patients undergoing emergency general surgery in a tertiary care centre over four weeks. Data were extracted from patient notes and anonymised for statistical analysis. Results No statistically significant associations were found with the studied variables and decision to incision time. However, this study identified clear delays, with 66% of emergency operations taking place after target time assigned by NCEPOD classification. It identified trends in varying decision to incision time in patient and procedure type. It also identified issues with documentation and an association between longer decision to incision time and post-operative length of stay. Conclusion This study highlights important delays in emergency general surgery. Decision to incision time reveals important trends and, with larger sample sizes, may identify areas which hinder time-sensitive procedures. This study recommends that decision time could be more formally incorporated into surgical documentation to better monitor delays. The findings of this study could inform future research, which is required to determine the true potential of using decision to incision time interval in emergency general surgery.

SHARP risk score: A predictor of poor outcomes in adults admitted for emergency general surgery: A prospective cohort study

PurposePost-operative complications following emergency abdominal surgery are associated with significant morbidity and mortality. Despite the knowledge of prognostic factors associated with poor surgical outcomes; few have described risks of poor outcomes based on admission information in acute surgical setting. We aimed to derive a simple, point-of-care risk scale that predicts adults with increased risk of poor outcomes. MethodsWe used data from an international multi-centre prospective cohort study. The effect of characteristics; age, hypoalbuminaemia, anaemia, renal insufficiency and polypharmacy on 90-day mortality was examined using fully adjusted multivariable models. For our secondary outcome we aimed to test whether these characteristics could be combined to predict poor outcomes in adults undergoing emergency general surgery. Subsequently, the impact of incremental increase in derived SHARP score on outcomes was assessed. ResultsThe cohort consisted of 419 adult patients between the ages of 16–94 years (median 52; IQR(39) consecutively admitted to five emergency general surgical units across the United Kingdom and one in Ghent, Belgium. In fully adjusted models the aforementioned characteristics; were associated with 90-day mortality. SHARP score was associated with higher odds of mortality in adults who underwent emergency general surgery, with a SHARP score of five also being associated with an increased length of hospital stay. ConclusionsSHARP risk score is a simple prognostic tool, using point-of-care information to predict poor outcomes in patients undergoing emergency general surgery. This information may be used to improve management plans and aid clinicians in delivering more person-centred care. Further validation studies are required to prove its utility.

Predicting Outcomes in Emergency General Surgery Patients Using Preoperative Model for End-Stage Liver Disease Score

INTRODUCTION: The Model for End-Stage Liver Disease (MELD) score is commonly used to predict liver-related mortality postoperatively in cirrhotic patients. Multiple studies have demonstrated its value in predicting adverse outcomes for patients without reported liver failure, all focused on outcomes for elective procedures. This study examined MELD scores and 30-day outcomes in adult patients undergoing emergent general surgery procedures. METHODS: This was a retrospective analysis of the American College of Surgeons NSQIP database from 2014 to 2018. General surgery patients more than 18 years old who underwent an emergent procedure were included. Patients who were missing preoperative laboratory values for sodium, international normalized ratio, bilirubin, and creatinine were excluded. A univariable and multivariable logistic regression with a nonlinear restricted cubic spline of the MELD score was performed. The models were controlled for age, sex, race, diabetes, smoking, COPD, congestive heart failure, and disseminated cancer. All analysis was done using R Version 4.1.2. RESULTS: A total of 123,104 patients were analyzed with 34.8% (n = 42,799) with MELD 10 to 19, 11.2% (n = 13,826) with MELD 20 to 29, and 1.3% (n = 1,575) with MELD 30 to 39. Of these patients, 7.8% (n = 9,640) died, 6.9% (n = 8,539) developed pneumonia, and 14.9% (n = 18,356) had a bleeding event within 30 days. The probability of mortality (chi-square [3df] = 7,170.7, p < 0.001), pneumonia (chi-square [3df] = 1,568.3, p < 0.001), and bleeding (chi-square [3df] = 6,436.5, p < 0.001) significantly correlate with MELD score (Fig. 1). The probability of mortality for a MELD 10 is 4.5%, for a MELD 20 is 15.6%, and for a MELD 30 is 36.0% for the average patient.Figure 1CONCLUSION: Across all variables, postoperative outcomes worsened in a nonlinear manner as MELD increased. MELD scores can be used in preoperative assessment of patients undergoing emergency general surgery.

Use of failure-to-rescue after emergency surgery as a dynamic indicator of hospital resilience during the COVID-19 pandemic. A multicenter retrospective propensity score-matched cohort study

BackgroundSurgical failure-to-rescue (FTR, death rate following complications) is a reliable cross-sectional quality of care marker, but has not been evaluated dynamically. We aimed to study changes in FTR following emergency surgery during the COVID-19 pandemic. Material and methodsMatched cohort study including all COVID-19-non-infected adult patients undergoing emergency general surgery in 25 Spanish hospitals during COVID-19 pandemic peak (March–April 2020), non-peak (May–June 2020), and 2019 control periods. A propensity score-matched comparative analysis was conducted using a logistic regression model, in which period was regressed on observed baseline characteristics. Subsequently, a mixed effects logistic regression model was constructed for each variable of interest. Main variable was FTR. Secondary variables were post-operative complications, readmissions, reinterventions, and length of stay. Results5003 patients were included (948, 1108, and 2947 in the pandemic peak, non-peak, and control periods), with comparable clinical characteristics, prognostic scores, complications, reintervention, rehospitalization rates, and length of stay across periods. FTR was greater during the pandemic peak than during non-peak and pre-pandemic periods (22.5% vs. 17.2% and 12.7%), being this difference confirmed in adjusted analysis (odds ratio [OR] 2.13, 95% confidence interval [95% CI] 1.27–3.66). There was sensible inter-hospital variability in FTR changes during the pandemic peak (median FTR change +8.77%, IQR 0–29.17%) not observed during the pandemic non-peak period (median FTR change 0%, IQR -6.01−6.72%). Greater FTR increase was associated with higher COVID-19 incidence (OR 2.31, 95% CI 1.31–4.16) and some hospital characteristics, including tertiary level (OR 3.07, 95% CI 1.27–8.00), medium-volume (OR 2.79, 95% CI 1.14–7.34), and high basal-adjusted complication risk (OR 2.21, 95% CI 1.07–4.72). ConclusionFTR following emergency surgery experienced a heterogeneous increase during different periods of the COVID-19 pandemic, suggesting it to behave as an indicator of hospital resilience. FTR monitoring could facilitate identification of centres in special needs during ongoing health care challenges.

Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study

BackgroundFrailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. MethodsA retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. ResultsWe identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60–0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64–0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. ConclusionsIn patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.

Emergency General Surgery: Predicting Morbidity and Mortality in the Geriatric Population.

Introduction Numerous scoring systems have been created to predict the risk of morbidity and mortality in patients undergoing emergency general surgery (EGS). In this article, we compared the different scoring systems utilized at Humanitas Research Hospital and analyzed which one performed the best when assessing geriatric patients (>65 years of age). The scoring systems that were utilized were the APACHE II (Acute Physiology and Chronic Health Evaluation II), ASA (American Society of Anesthesiologists), ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program), Clinical Frailty Score, and the Clavien–Dindo classification as control.Materials and Methods We compiled a database consisting of all patients over the age of 65 who underwent EGS in a consecutive 24-month period between January 1, 2017 and December 31, 2018. We used the biostatistical program “Stata Version 15” to analyze our results. Results We found 213 patients who matched our inclusion criteria. Regarding death, we found that the ACS-NSQIP death calculator performed the best with an area under the curve of 0.9017 (odds ratio: 1.09; 95% confidence interval: 1.06–1.12). The APACHE II score had the lowest discriminator when predicting death. Considering short-term complications, the Clavien–Dindo classification scored highly, while both the APACHE II score and Clinical Frailty Score produced the lowest results. Conclusion The results obtained from our research showed that scoring systems and classifications produced different results depending on whether they were used to predict deaths or short-term complications among geriatric patients undergoing EGS.

1029 EVEN LIMITED GERIATRICIAN INVOLVEMENT REDUCES LENGTH OF STAY FOR ALL-AGE ACUTE GENERAL SURGERY PATIENTS

Abstract Background More than half of patients undergoing emergency general surgery are older than 651. The Emergency Laparotomy and Frailty (ELF) study identified that frail patients (CFS ≥5) were vulnerable to adverse outcomes and longer hospital stays and should be reviewed by a geriatrician2. The 2021 National Emergency Laparotomy Audit (NELA) found that only 27% were reviewed by a geriatrician1. Local problem A local hospital had no routine geriatrician input to perioperative care of older people admitted under the care of general surgeons. Method/Intervention In one month prior to intervention, we noted CFS recorded once and a geriatrician involved in only 3 patients over the age of 65 (n = 35). We introduced a service comprising twice-weekly geriatrician-led multi-disciplinary team (MDT) meetings of all-age patients followed by selected patient ward rounds. This equated to 2.5 Programmed Activity’s (PA) per week. After another month we measured the number of patients having CFS recorded, those who had geriatrician involvement and length of stay. We also surveyed members of the MDT. Results All 31 patients aged over 65 received geriatrician input with 93.5% having a CFS recorded. Length of stay of all-age patients (n = 75) was reduced from 12.8 to 8.8 days, with the most significant reduction of 6.5 days in over 65’s (16.7 to 10.2); &amp;gt;200 bed days saved for older people. The MDT comments included: ‘improved MDT communication’, ‘early identification of discharge barriers’ and ‘pro-active approach’. Conclusion NELA highlights that consistent geriatrician input remains generally poor. Even a limited geriatrician-led service can be highly effective at guaranteeing review of appropriate patients in line with recommendations from NELA. Alongside targeted patient review geriatricians can support and lead decision making of all-age patients. This cost-effective strategy can reduce length of stay for young and old alike and gained excellent feedback from the MDT.