Patients Undergoing Emergency General Surgery Research Articles

Hospital Operative Volume and Quality Indication for General Surgery Operations Performed Emergently in Geriatric Patients

Within the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes can require a structured system of surgical care based on key quality indicators. To investigate this, the current study sought to answer 2 questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume will geriatric patients undergoing an emergency operation achieve at or better than average mortality risk? Retrospective cohort study of geriatric patients (aged 65 years and older) who underwent 1 of 10 EGS operations identified from the California State Inpatient Database (2010 to 2011). β-Logistic generalized linear regression was used, with the hospital as the unit of analysis, to investigate the relationship between hospital operative volume and in-hospital riskv-adjusted mortality. Hospital operative volume thresholds to optimize probability of survival were defined. There were 41,860 operations evaluated at 299 hospitals. For each operation, mortality decreased as hospital emergency operative volume increased (p < 0.001 for each operation); for every standardized increase in volume (meaning+1 natural logarithm of volume), the reduction in mortality ranged from 14% for colectomy to 61% for appendectomy. Hospital volume thresholds, which optimize to 95% probability of survival, varied by procedure, with a mean of 14 operations over 2 years. More than 50% of hospitals did not meet the threshold benchmarks, representing 22% of patients. Survival rates for geriatric patients were improved substantially when emergency operations were performed at hospitals with higher operative volumes. Consistent with all active Quality Programs of the American College of Surgeons, hospital operative volume appears to be an important metric of surgical quality for older patients undergoing emergency operations.

Most of the variation in length of stay in emergency general surgery is not related to clinical factors of patient care.

Hospital length of stay (LOS) is currently recognized as a key quality indicator. We sought to investigate how much of the LOS variation in the high-risk group of patients undergoing Emergency general surgery could be explained by clinical versus nonclinical factors. Using the 2007 to 2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we included all patients who underwent an emergency appendectomy, cholecystectomy, colectomy, small intestine resection, enterolysis, or hernia repair. American College of Surgeons National Surgical Quality Improvement Program defines emergency surgery as one that is performed no later than 12 hours after admission or symptom onset. Using all the ACS-NSQIP demographic, preoperative (comorbidities, laboratory variables), intraoperative (e.g., duration of surgery, wound classification), and postoperative variables (i.e., complications), we created multivariable linear regression models to predict LOS. LOS was treated as a continuous variable, and the degree to which the models could explain the variation in LOS for each type of surgery was measured using the coefficient of determination (R). A total of 215,724 patients were included. The mean age was 47.1 years; 52.0% were female. In summary, the median LOS ranged between 1 day for appendectomies (n = 124, 426) and cholecystectomies (n = 21,699) and 8 days for colectomies (n = 19,557) and small intestine resections (n = 7,782). The R for all clinical factors ranged between 0.28 for cholecystectomy and 0.44 for hernia repair, suggesting that 56% to 72% of the LOS variation for each of the six procedures studied cannot be explained by the wide range of clinical factors included in ACS-NSQIP. Most of the LOS variation is not explained by clinical factors and may be explained by nonclinical factors (e.g., logistical delays, insurance type). Further studies should evaluate these nonclinical factors to identify target areas for quality improvement. Epidemiological study, level III.

Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi.

BackgroundIn sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD.MethodsUtilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD.ResultsOf 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment.ConclusionIHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.

Emergency general surgery in geriatric patients: How should we evaluate hospital experience?

As the aging American population poses unique challenges to acute care services, we determined if either hospital proportion or annual volume of geriatric patients undergoing emergency general surgery (EGS) procedures is associated with outcomes. Using criteria from the American Association of the Surgery of Trauma, we identified five EGS procedures in the 2012-2015 Nationwide Inpatient Sample common in geriatric patients (65+ years). We defined hospital proportion as the fraction of geriatric EGS patients divided by all EGS patients, where volume was the raw number of geriatric EGS patients. We then divided hospitals into quartiles both by proportion and then by volume of geriatric patients. Multivariable logistic regressions compared four outcomes between these quartiles: mortality, complications, failure to rescue (FTR; death after a complication), and extended length of stay (LOS; procedure-specific top decile of patients). We identified 25,084 complex EGS procedures in geriatric patients at 3,528 hospitals (mortality, 10.6%; complications, 30.5%; FTR, 27.7%; extended LOS, 9.1%). The median hospital proportion of geriatric patients among EGS procedures was 42.8% (interquartile range, 33.3-52.2%), whereas the median hospital geriatric EGS volume after nationwide weighting was 40 per year (interquartile range, 20-70/year). After adjustment, the lowest hospital proportion quartile relative to the highest was associated with adverse outcomes: mortality (odds ratio, 1.21 [95% confidence interval, 1.03-1.44]), complications (1.16 [1.05-1.29]), FTR (1.32 [1.08-1.63]), and extended LOS (1.30 [1.12-1.50]). The lowest volume quartile relative to the highest was not associated with adverse outcomes. As the hospital proportion of geriatric patients increased by 10%, the odds of all adverse outcomes decreased: mortality by 7%, complications by 4%, FTR by 9%, and extended LOS by 8%. When accounting for both, hospital proportion of geriatric EGS patients but not hospital volume is associated with postoperative outcomes, having important implications for quality improvement initiatives, benchmarking endeavors, and health services research. Care management, level IV; prognostic, level III.

Do outcomes in emergency general surgery vary for minority patients based on surgeons’ racial/ethnic case mix?

BackgroundWe hypothesized that Black and Hispanic patients undergoing Emergency General Surgery (EGS) with surgeons who treat higher proportions of minority patients will experience better outcomes. MethodsUsing the Florida State Inpatient Database (2010–2014), we performed multivariable regression to assess complications in patients undergoing EGS as a function of patient race and the proportion of Black, Hispanic, or White patients treated by the surgeon during the study period. Analyses were clustered by hospital and adjusted for patient age, comorbidities, sex, insurance, and hospital-level variables. Results5471 surgeons were distributed across 204 hospitals. Of the 520,024 patients included, 67% were White, 16.5% were Black, and 14.2% were Hispanic. For non-White patients undergoing EGS, the increased likelihood of sustaining a complication relative to White patients (OR 1.09, 95% confidence interval [CI] 1.07–1.11) decreased when treated by surgeons whose caseload consisted of higher proportions of Black/Hispanic patients (aOR 0.88, 95% CI 0.78–0.99). ConclusionBlack patients undergoing EGS are at higher risk for experiencing complications when treated by surgeons whose caseload consists of higher proportions of White patients.

Effect of diabetes mellitus on postoperative outcomes in patients undergoing emergency general surgery procedures.

Background: Diabetes Mellitus (DM) is a global health hazard affecting millions of people globally. A nationwide study conducted in Saudi Arabia showed the incidence and prevalence of DM were gradually increasing. Studies on the outcomes of emergency general surgery operations of diabetic patients are limited. The objective of this study is to compare the outcomes of diabetic patients undergoing emergency general surgery operations compared to those who are non-diabetic. Methods: Data for this cross-sectional study were collected using an observational clinical case series database, retrospectively, for patients undergoing emergency general surgery operations between July 2017 and December 2018 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were classified into diabetic and non-diabetic groups based on previous diagnosis at the time of presentation for their emergency procedure. Statistical analysis was utilized to investigate the association of diabetes with factors related to morbidity and mortality. Results: The total number of the participants was 325, wherein 177 (54.5%) were males. 185 (57%) were diabetic. We found significant association between diabetes mellitus and ICU admission and hospital readmissions compared to non-diabetic patients (odds ratio 1.772, relative risk 1.257 vs. 0.709, p=0.025). However, no statistically significant association was found between the diagnosis of diabetes and inhospital or 30-day mortality after emergency general surgery procedures. Conclusion: There are significant associations of the diagnosis of diabetes and worse postoperative outcomes in patients undergoing emergency general surgery procedures. Health care providers should give special attention as well as prompt and watchful perioperative care for this patients' population.

High-Risk Comorbidity Combinations in Older Patients Undergoing Emergency General Surgery.

Over a million older patients in the United States are admitted yearly for emergency general surgery (EGS) conditions. Seven procedure types dominate: colon, small bowel, gallbladder, ulcer disease, adhesiolysis, appendix, and laparotomy operations. A higher comorbidity burden is known to increase mortality in this population, but the impact of specific comorbidity combinations is unknown. Our objectives were to (1) characterize the distribution of procedures, comorbidities, and outcomes for older patients undergoing EGS; and (2) apply a data-driven approach (association rule mining) to identify comorbidity combinations associated with disproportionately high mortality. Cross-sectional study of patients 65 years and older who underwent one of the seven procedures previously cited, taken from the 2011 Nationwide Inpatient Sample. A total of 280 885 patient encounters were identified. In-hospital mortality, procedures, and comorbidities based on the Elixhauser Comorbidity Index. Overall mortality was 5.6%. The most common procedures were gallbladder (33.7%), ulcer surgery (21.5%), and adhesiolysis (21.0%). Mortality increased for all procedures as patients aged. Comorbidities associated with the highest mortality included coagulopathy (adjusted odds ratio [aOR] = 3.74; 95% confidence interval [CI] = 3.41-4.11; p < .001), fluid and electrolyte disorders (FED) (aOR = 2.89; 95% CI = 3.66-3.14; p < .001), and liver disease (aOR = 1.89; 95% CI = 1.61-2.22; p < .001). Three-way comorbidity combinations most highly associated with mortality were coagulopathy, FED, and peripheral vascular disease (aOR = 5.10; 95% CI = 4.17-6.24; p < .001), and coagulopathy, FED, and chronic pulmonary disease (aOR = 4.83; 95% CI = 4.00-5.82; p < .001). For older patients, combinations of comorbidities portend additional risk beyond single comorbidities, and the associated risk burden is driven by the specific constellation of comorbidities present. Future work must continue to examine the effect of co-occurring diseases to provide personalized and realistic prognostication for older patients undergoing EGS. J Am Geriatr Soc 67:503-510, 2019.

Kras Mutational and Pathologic Response to Preoperative Morbidity in Geriatric Patients Undergoing Emergency General Surgery

Kras Mutational and Pathologic Response to Preoperative Morbidity in Geriatric Patients Undergoing Emergency General Surgery

Prospective Evaluation of Preoperative Cognitive Impairment and Postoperative Morbidity in Geriatric Patients Undergoing Emergency General Surgery

Khan, Muhammad N. MD; Zeeshan, Muhammad MD; Tang, Andrew L. MD, FACS; O’Keeffe, Terence MBChB, FACS; Hamidi, Mohammad MD; Zakaria, El Rasheid MD, PhD; Kulvatunyou, Narong MD, FACS; Gries, Lynn M. MD; Joseph, Bellal MD, FACS Author Information

Failure to Rescue in Octogenarian Patients Undergoing Emergency General Surgery: An American College of Surgeons NSQIP Study

Failure to Rescue in Octogenarian Patients Undergoing Emergency General Surgery: An American College of Surgeons NSQIP Study

The Early Impact of Medicaid Expansion on Uninsured Patients Undergoing Emergency General Surgery

BackgroundUnder the Affordable Care Act, eligibility for Medicaid coverage was expanded to all adults with incomes up to 138% of the federal poverty level in states that participated. We sought to examine the national impact Medicaid expansion has had on insurance coverage for patients undergoing emergency general surgery (EGS) and the cost burden to patients. Materials and methodsThe National Inpatient Sample (NIS) was used to identify adults ≥18 y old who underwent the 10 most burdensome EGS operations (defined as a combination of frequency, cost, and morbidity). Distribution of insurance type before and after Medicaid expansion and charges to uninsured patients was evaluated. Weighted averages were used to produce nationally representative estimates. ResultsA total of 6,847,169 patients were included. The percentage of uninsured EGS patients changed from 9.4% the year before Medicaid expansion to 7.0% after (P < 0.01), whereas the percentage of patients on Medicaid increased from 16.4% to 19.4% (P < 0.01). The cumulative charges to uninsured patients for EGS decreased from $1590 million before expansion to $1211 million after. ConclusionsIn the first year of Medicaid expansion, the number of uninsured EGS patients dropped by 2.4%. The cost burden to uninsured EGS patients decreased by over $300 million.

Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes.

Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes. We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters. We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes. Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients. Prognostic and epidemiological, level IV.

The Impact of Frailty on Postoperative Cardiopulmonary Complications in the Emergency General Surgery Population.

Background The burden of frail patients undergoing emergency general surgery (EGS) is increasing rapidly and this population is particularly susceptible to postoperative cardiopulmonary complications and mortality. We aimed to determine the association between frailty, as defined by the previously described modified frailty index (mFI), and postoperative respiratory complications (unplanned reintubation, pneumonia, and prolonged ventilation), cardiac complications (myocardial infarction and cardiac arrest), and mortality. We also sought to identify the most significant determinants of frailty in the highest risk patients based on the specific variables comprising the mFI. Methods We performed a retrospective observational analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Files from 2005 to 2015 identified 132,765 inpatients who underwent EGS. mFI scores were calculated for each patient. The effect of increasing frailty on unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality was evaluated using bivariate analysis. Multivariable logistic regression was used to compare mFI with additional predictor variables including race, gender, physical status as defined by the American Society of Anesthesiologists, disseminated cancer, renal failure, smoking status, sepsis, wound presence/classification, dyspnea, and previous ventilator dependence. Results Unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality were significantly associated with frailty, and the odds of each postoperative complication increased with increasing mFI score. Of the frailest patients (mFI ≥3) that experienced cardiopulmonary complications or mortality, the variables of the mFI that contributed most to frailty were hypertension requiring medication and functional status before surgery. Conclusions A higher mFI score is associated with increased odds of postoperative cardiopulmonary complications and mortality in the EGS population. Specific variables of the mFI can also provide valuable information for assessing odds in the frailest patients undergoing EGS.

Venous Thromboembolism-Related Readmission in Emergency General Surgery Patients: A Role for Prophylaxis on Discharge?

Patients undergoing emergency general surgery (EGS) operations experience high rates of venous thromboembolism (VTE). The rates at which thrombus formation occurs after discharge, and whether VTE prophylaxis at discharge might be warranted to prevent readmission, are unknown. This analysis aimed to determine risk factors associated with VTE formation after discharge for EGS operations. An analysis of the American College of Surgeons NSQIP database from 2013 and 2014 of patients undergoing 10 common EGS operations in an emergent fashion. Multivariable logistic regression modeling was used to determine factors that predicted VTE after discharge. A total of 130,036 patients were included. The 30-day VTE rate was 1.30%, with 35% of all VTEs occurring after discharge. Of those who had VTE develop after discharge, 69.4% required readmission. Predictive factors for post-discharge VTE included prolonged length of stay (odds ratio [OR] 5.25; p < 0.001), presence of metastatic cancer (OR 2.23; p < 0.001), urinary tract infection (OR 1.91; p < 0.001), and postoperative sepsis (OR 1.55; p < 0.001). Identified high-risk groups had a rate of readmission with thrombus 6 times greater than that of average-risk EGS patients. More than 30% of VTEs in the EGS population occur after discharge; of these, a vast majority require readmission. Select high-risk EGS subgroups might benefit from prophylactic anticoagulation at discharge.

Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care.

Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality. Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile. Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01). Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes. Epidemiological, level III; Care management, level IV.

Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: What is the role of Plasma Hemoglobin A1c?

Plasma hemoglobin A1c (HbA1c) reflects quality of glucose control in diabetic patients. Literature reports that patients undergoing surgery with an elevated HbA1c level are associated with increased postoperative morbidity and mortality. The aim of our study was to evaluate the impact of HbA1c level on outcomes after emergency general surgery (EGS). We performed a 3-year analysis of our prospectively maintained EGS database. Patients who had HbA1c levels measured within 3 months before surgery were included. Patients were divided into two groups (HbA1c < 6 and HbA1c ≥ 6). Our primary outcome measures included in-hospital complications (major and minor complications), hospital and intensive care unit length of stay, and mortality. Secondary outcomes measures were 30-day complications, readmissions, and mortality. Multivariate and linear regressions were performed. Of the 402 study patients, mean age was 61 ± 12 years, 53% were females, and 63.8% were diabetics. Overall, 49% had an HbA1c ≥ 6%; the mortality rate was 6%. Those with hypertension, history of coronary artery disease, and body mass index of 30 kg/m or greater were more likely to have HbA1c of 6.0% or greater. 7.9% patients experienced major complications. Patients with HbA1c of 6% or greater had a higher complication rate (36% vs 11%, p < 0.001) than those with HbA1c less than 6%. However there was no difference in mortality between two groups (p = 0.09). After controlling for confounders, HbA1c ≥ 6.0% (odds ratio [OR], 2.9; p < 0.01) and a postoperative random blood sugar (RBS) of 200 mg/dL or greater (OR, 2.3; p < 0.01) were independent predictors of major complications. Patients with both HbA1c of 6.0% or greater and postoperative RBS of 200 or greater had higher odds (OR, 4.2; p < 0.01) of developing major complication. After adjusting for confounders, a higher HbA1c was independently correlated with a higher postoperative RBS (b = 0.494, [19.7-28.4], p = 0.02), but there was no correlation with the preoperative RBS. Patients with HbA1c of 6.0% or greater and a postoperative RBS of 200 mg/dL or greater have a four times higher risk of developing major complications after EGS. A preoperative HbA1c can stratify patients prone to develop postoperative hyperglycemia, regardless of their preoperative RBS. Prognostic, level III.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission

Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30-day mortality, postoperative duration of stay >30days, and complications. Patients >18years in The American College of Surgeons National Surgical Quality Improvement Program (2011-2014) who had 1 of 7 emergency operations between hospital day 3-18 were included. Patients with operations >95th percentile after admission (>18days; n=581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes. Of 10,093 patients with emergency operations, most were elderly (median 66years old [interquartile ratio: 53-77years]), white, and female. Postoperative 30-day mortality was 12.6% (n=1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11-18 compared with day 3-6 was associated with death (odds ratio 1.6 [1.3-2.0]), postoperative duration of stay >30days (odds ratio 2.0 [1.6-2.6]), and complications (odds ratio 1.5 [1.3-1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8-10.4]). Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only.

The Association of Frailty With Outcomes and Resource Use After Emergency General Surgery: A Population-Based Cohort Study.

Older patients undergoing emergency general surgery (EGS) experience high rates of postoperative morbidity and mortality. Studies focused primarily on elective surgery indicate that frailty is an important predictor of adverse outcomes in older surgical patients. The population-level effect of frailty on EGS is poorly described. Therefore, our objective was to measure the association of preoperative frailty with outcomes in a population of older patients undergoing EGS. We created a population-based cohort study using linked administrative data in Ontario, Canada, that included community-dwelling individuals aged >65 years having EGS. Our main exposure was preoperative frailty, as defined by the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. The Adjusted Clinical Groups frailty-defining diagnoses indicator is a binary variable that uses 12 clusters of frailty-defining diagnoses. Our main outcome measures were 1-year all-cause mortality (primary), intensive care unit admission, length of stay, institutional discharge, and costs of care (secondary). Of 77,184 patients, 19,779 (25.6%) were frail. Death within 1 year occurred in 6626 (33.5%) frail patients compared with 11,366 (19.8%) nonfrail patients. After adjustment for sociodemographic and surgical confounders, this resulted in a hazard ratio of 1.29 (95% confidence interval [CI] 1.25-1.33). The risk of death for frail patients varied significantly across the postoperative period and was particularly high immediately after surgery (hazard ratio on postoperative day 1 = 23.1, 95% CI 22.3-24.1). Frailty was adversely associated with all secondary outcomes, including a 5.82-fold increase in the adjusted odds of institutional discharge (95% CI 5.53-6.12). After EGS, frailty is associated with increased rates of mortality, institutional discharge, and resource use. Strategies that might improve perioperative outcomes in frail EGS patients need to be developed and tested.

A calculator for mortality following emergency general surgery based on the American College of Surgeons National Surgical Quality Improvement Program database.

The complex nature of current morbidity and mortality predictor models do not lend themselves to clinical application at the bedside of patients undergoing emergency general surgery (EGS). Our aim was to develop a simplified risk calculator for prediction of early postoperative mortality after EGS. EGS cases other than appendectomy and cholecystectomy were identified within the American College of Surgeons National Surgery Quality Improvement Program database from 2005 to 2014. Seventy-five percent of the cases were selected at random for model development, whereas 25% of the cases were used for model testing. Stepwise logistic regression was performed for creation of a 30-day mortality risk calculator. Model accuracy and reproducibility was investigated using the concordance index (c statistic) and Pearson correlations. A total of 79,835 patients met inclusion criteria. Overall, 30-day mortality was 12.6%. A simplified risk model formula was derived from five readily available preoperative variables as follows: 0.034*age + 0.8*nonindependent status + 0.88*sepsis + 1.1 (if bun ≥ 29) or 0.57 (if bun ≥18 and < 29) + 1.16 (if albumin < 2.7), or 0.61 (if albumin ≥ 2.7 and < 3.4). The risk of 30-day mortality was stratified into deciles. The risk of 30-day mortality ranged from 2% for patients in the lowest risk level to 31% for patients in the highest risk level. The c statistic was 0.83 in both the derivation and testing samples. Five readily available preoperative variables can be used to predict the 30-day mortality risk for patients undergoing EGS. Further studies are needed to validate this risk calculator and to determine its bedside applicability. Prognostic/epidemiological study, level III.

Effect of day of the week on short- and long-term mortality after emergency general surgery.

The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality. This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival. A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday. There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.