Patients Undergoing Emergency General Surgery Research Articles

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.

Clinical and financial impact of chronic kidney disease in emergency general surgery operations

IntroductionChronic kidney disease is frequently encountered in clinical practice and often requires more intricate management strategies. However, its impact on outcomes of patients warranting emergency general surgery has not been well characterized. The present study examined the association of chronic kidney disease stage on in-hospital outcomes and readmission following emergency general surgery using a nationally representative cohort. MethodsThe 2016–2018 Nationwide Readmissions Database was queried to identify all adult hospitalizations for 1 of 6 common emergency general surgery operations. Patients were stratified by severity of chronic kidney disease into stages 1–3, stages 4–5, end-stage renal disease, and others (non–chronic kidney disease). Regression models were used to examine factors associated with mortality, readmissions, and costs. ResultsOf an estimated 985,101 patients undergoing emergency general surgery, 60,949 (6.2%) had a diagnosis of chronic kidney disease (1–3: 67.1%, 4–5: 11.5%, end-stage renal disease: 23.4%). Unadjusted rates of mortality increased with chronic kidney disease in a stepwise manner (2.1% in non–chronic kidney disease to 16.9 in end-stage renal disease, P < .001), as did 90-day readmissions (9.2% to 29.7%, respectively, P < .001). After adjustment, all stages of chronic kidney disease exhibited increases in risk-adjusted rates of mortality (range: 0.2% in chronic kidney disease 1–3 to 12.2% in end-stage renal disease, P < .001). Relative to non–chronic kidney disease, end-stage renal disease had the greatest cost burden for those undergoing small bowel resection (β +$83,600) and the least in cholecystectomy (+$30,400). ConclusionChronic kidney disease severity is associated with a stepwise increase in mortality, hospitalization costs, and 90-day readmissions. Our findings may better inform shared decision-making and have implications in benchmarking. Further studies for optimal management strategies in this high-risk group are needed.

Derivation and external validation of a 30-day mortality risk prediction model for older patients having emergency general surgery

BackgroundOlder people (≥65 yr) are at increased risk of morbidity and mortality after emergency general surgery. Risk prediction models are needed to guide decision making in this high-risk population. Existing models have substantial limitations and lack external validation, potentially limiting their applicability in clinical use. We aimed to derive and validate, both internally and externally, a multivariable model to predict 30-day mortality risk in older patients undergoing emergency general surgery. MethodsAfter protocol publication, we used the National Surgical Quality Improvement Program (NSQIP) database (2012–6; estimated to contain 90% data from the USA and 10% from Canada) to derive and internally validate a model to predict 30-day mortality for older people having emergency general surgery using logistic regression with elastic net regularisation. Internal validation was done with 10-fold cross-validation. External validation was done using a temporally separate health administrative database exclusively from Ontario, Canada. ResultsOverall, 6012 (12.0%) of the 50 221 patients died within 30 days. The model demonstrated strong discrimination (area under the curve [AUC]=0.871) and calibration across the spectrum of observed and predicted risks. Ten-fold internal cross-validation demonstrated minimal optimism (AUC=0.851, optimism 0.019 [standard deviation=0.06]) with excellent calibration. External validation demonstrated lower discrimination (AUC=0.700) and degraded calibration. ConclusionA multivariable mortality risk prediction model was strongly discriminative and well calibrated internally. However, poor external validation suggests the model may not be generalisable to non-NSQIP data and hospitals. The findings highlight the importance of external validation before clinical application of risk models.

Evaluation of surgical Apgar score as a predictor of postoperative complications in emergency general surgical patients in a Nigerian teaching hospital

Aims: The aim of this study was to evaluate the ability of the surgical Apgar score (SAS) to predict post-operative complications at the University College Hospital (UCH), Ibadan, Nigeria. Methods: This was a retrospective study of adult patients undergoing emergency general surgery procedures. The main end-points were post-operative mortality and surgical site infection (SSI). The ability of the SAS to predict post-operative outcomes was determined using the receiver operating characteristics curve (ROC). Statistical significance was defined by a p value of less than 0.05. Results: The mean SAS was 5.6 ± 1.7 with majority of patients (61.4%, n = 70) being at medium risk (Apgar score 5–7) for post-operative complication. The most common post-operative complication was SSI (47.1%, n = 25) with a 30-day mortality of 9.6%. The ROC curve showed that the SAS is a poor predictor of post-operative complications (Area under the curve [AUC] = 0.408) and mortality (AUC = 0.394). However, there is a statistically significant association between mean SAS and occurrence of post-operative complications (p = 0.026). Conclusion: The SAS does not predict post-operative complications in adult patients undergoing emergency general surgery procedures.

Impact of Venous Thromboembolism on Readmissions and Resource Use Following Emergency General Surgery.

Acute deep vein thrombosis and pulmonary embolism collectively known as venous thromboembolism (VTE), are associated with increased risk of poor clinical sequelae during inpatient hospitalizations. We examined the association of VTE with mortality, readmissions, and costs among patients undergoing emergency general surgery (EGS) operations using a national cohort. Adult hospitalizations for EGS (laparotomy, small bowel resection, large bowel resection, appendectomy, lysis of adhesions, cholecystectomy, and repair of perforated ulcer) within two days of admission were identified in the 2016-18 Nationwide Readmissions Database. Hospitalizations were stratified based on diagnosis of VTE and others (n-VTE). Of an estimated 860,747 EGS patients 7,513, (.87%) developed VTE during the index hospitalization. Patients in the VTE group were on average older (65.5 ± 15.3 vs 54.8 ± 18.6years, P < .001) and more commonly male (46.7 vs 39.3%, P < .001). Venous thromboembolism was independently associated with greater odds of mortality (AOR:1.7 95% CI 1.6-1.9), increased costs (+27,700 95% CI 23,100-28,300) and greater odds of 30-day readmissions (AOR 1.3 95% CI 1.2-1.4). Despite national efforts to reduce its incidence, VTE affects nearly 1/100 EGS patients and is associated with increased odds of mortality as well as costs, and readmissions. Tailored approaches are warranted to reduce the impact of this pernicious complication.

Emergency General Surgery Transfer and Effect on Inpatient Mortality and Post-Discharge Emergency Department Visits: A Propensity Score Matched Analysis.

Patients undergoing emergency general surgery (EGS) and interhospital transfer (IHT) have increased mortality. Prior analyses of IHT have been limited by the inability to track post-discharge outcomes or have not included nonoperative EGS. We evaluated outcomes for IHT to our tertiary care facility compared with direct admission through the emergency department. Patients admitted directly (2015 to 2017) with a common EGS diagnosis (appendicitis, cholecystitis, choledocholithiasis, small bowel obstruction, and diverticulitis) were propensity score matched to patients transferred from another acute care hospital. Propensity score matching (PSM) was performed using patient characteristics, EGS diagnosis, comorbidities, and surgical critical care consultation. The primary outcome was inpatient mortality, and secondary outcomes were length of stay (LOS) 30-day hospital readmission. We identified 3,153 directly admitted patients and 1,272 IHT patients. IHT patients were older (mean 59.4 vs 51.5 years), had a higher Charlson comorbidity index (median 3 vs 1), White race (72% vs 49%), and BMI greater than 40 kg/m2 (11.6% vs 9.8%). After PSM, each group included 1,033 patients. IHT patients had a higher median LOS (5.5 days vs 3.8, p < 0.001), higher inpatient mortality (odds ratio [OR] 1.69, p = 0.03), and more complications (OR 1.57, p < 0.001). The rate of post-discharge 30-day hospital encounters was similar (OR 1.08, p = 0.460). However, IHT patients had more emergency department encounters (OR 1.35, p = 0.04) and fewer observation-status readmissions (OR 0.53, p = 0.01). After PSM to reduce confounding variables, patients with common EGS diagnoses transferred to a tertiary care facility have increased inpatient morbidity and mortality. The increased morbidity and resource utilization for these patients extends beyond the index hospital stay.

The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter.

The impact of interhospital transfer on outcomes of patients undergoing emergency general surgery (EGS) procedures is incompletely studied. We set out to determine if transfer before definitive surgical care leads to worse outcomes in EGS patients. Using the National Surgical Quality Improvement Project database (2013-2019), a retrospective cohort study was conducted including nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Time to surgery was recorded in days. The impact of interhospital transfer on outcomes (mortality, major complications, 30-day reoperations, and 30-day readmissions) and length of stay, according to procedure risk and time to surgery, were analyzed by multivariate logistic regression and inverse probability treatment of the weighting with treatment effect in the treated. A total of 329,613 patients were included in the study (284,783 direct admission and 44,830 transfers). Adjusted mortality (3.1% vs. 10.4%; adjusted odds ratio [AOR], 1.28; p < 0.001), major complications (6.7% vs. 18.9%; AOR, 1.39; p < 0.001), 30-day reoperations (3.1% vs. 6.4%; AOR, 1.22; p < 0.001), and length of stay (2 vs. 5) were higher in transferred patients. Transfer had no effect on 30-day readmissions (6% vs. 8.5%; AOR, 1.04; p = 0.063). These results were also observed in high-risk surgery patients and in the late surgery group. The results were further confirmed after robust propensity score weighting was performed. We have demonstrated that delays to surgical intervention affect outcomes and that interhospital transfer of EGS patients for definitive surgical care has a negative impact on mortality, development of postoperative complications, and reoperations in patients undergoing high-risk EGS procedures. These findings may have important implications for regionalization of EGS care. Prognostic/epidemiological, level III.