Undergoing Emergency General Surgery Research Articles

Procedure Risk vs Frailty in Outcomes for Elderly Emergency General Surgery Patients: Results of a National Analysis.

The direct association between procedure risk and outcomes in elderly emergency general surgery (EGS) patients 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 EGS patients is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly EGS patients compared to frailty. Elderly patients (age > 65) undergoing emergency general surgery 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 Non-Frail, mFI 1-2 Frail, and mFI ≥3 Severely Frail) and based on procedure risk. Multivariable regression models and Receiving Operative Curve (ROC) analysis were used to determine risk factors associated with outcomes. A total of 59,633 elderly EGS patients were classified into non-frail (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 to frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly EGS patients compared to frailty. Assessing frailty in the elderly EGS patient population without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.

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.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures

BackgroundDespite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. MethodsWe performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. ResultsAmong our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. ConclusionSevere intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

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.

A National Analysis of Racial and Sex Disparities Among Interhospital Transfers for Emergency General Surgery Patients and Associated Outcomes

IntroductionStudies focusing on Emergency General Surgery (EGS) and Interhospital Transfer (IHT) and the association of race and sex and morbidity and mortality are yet to be conducted. We aim to investigate the association of race and sex and outcomes among IHT patients who underwent emergency general surgery. MethodsA retrospective review of adult patients who were transferred prior to EGS procedures using the National Surgery Quality Improvement Project from 2014 to 2020. Multivariable logistic regression models were used to compare outcomes (readmission, major and minor postoperative complications, and reoperation) between interhospital transfer and direct admit patients and to investigate the association of race and sex for adverse outcomes for all EGS procedures. A secondary analysis was performed for each individual EGS procedure. ResultsCompared to patients transferred directly from home, IHT patients (n = 28,517) had higher odds of readmission [odds ratio (OR): 1.004, 95% confidence interval (CI) (1.002-1.006), P < 0.001], major complication [adjusted OR: 1.119, 95% CI (1.117-1.121), P < 0.001), minor complication [OR: 1.078, 95% CI (1.075-1.080), P < 0.001], and reoperation [OR: 1.014, 95% CI (1.013-1.015), P < 0.001]. In all EGS procedures, Black patients had greater odds of minor complication [OR 1.041, 95% CI (1.023-1.060), P < 0.001], Native Hawaiian and Pacific Islander patients had greater odds of readmission [OR 1.081, 95% CI (1.008-1.160), P = 0.030], while Asian and Hispanic patients had lower odds of adverse outcome, and female patients had greater odds of minor complication [OR 1.017, 95% CI (1.008-1.027), P < 0.001]. ConclusionsProcedure-specific racial and sex-related disparities exist in emergency general surgery patients who underwent interhospital transfer. Specific interventions should be implemented to address these disparities to improve the safety of emergency procedures.

Effect of emergency general surgery on postoperative performance status in patients aged over 90 years

BackgroundFunctional deterioration following emergency general surgery (EGS) poses a significant challenge in super-elderly patients. However, limited research has focused on assessing the deterioration in postoperative performance status (PS). This study aimed to investigate the impact of EGS on PS deterioration in super-elderly patients, and the extent to which deteriorated PS is recovered. MethodsThis historical cohort study comprised 77 super-elderly patients who underwent EGS between July 2015 and December 2020. Functional deterioration was evaluated by comparing preoperative and postoperative Eastern Cooperative Oncology Group Performance Status (ECOG-PS). The Emergency Surgical Score (ESS) was used as a risk-adjustment tool. Questionnaires were mailed to the patients and their families to assess post-discharge PS and obtain their impressions of EGS. ResultsPostoperative PS deteriorated in 35/77 patients (45.5 %). Significant differences were observed between the groups in terms of sex, serum C-reactive protein (CRP) levels, ESS scores, preoperative ECOG-PS, duration of operation, and major complications. Multivariate analysis of preoperative factors showed that ESS ≥7 (OR: 3.7, 95 % CI: 1.0–13), preoperative ECOG-PS ≤2 (OR: 5.9, 95 % CI: 1.7–21), and female sex (OR: 5.8, 95 % CI: 1.6–21) were associated with postoperative ECOG-PS deterioration. According to the questionnaire results, PS recovery post-discharge was observed in 6/36 (17 %) patients, and 34/36 (94 %) patients and their families expressed positive impressions of EGS. ConclusionsEGS in super-elderly patients highly caused a deterioration in their PS, particularly in patients with maintained preoperative PS. PS hardly recovered; however, most patients and their families had positive impressions of the EGS. Key messageWe assessed the pre- and postoperative performance status of super-elderly patients who underwent emergency general surgery. Surgery caused a marked deterioration in patients' functional performance, which seldom recovered postoperatively.

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.

Intensive care unit readmission and unexpected death after emergency general surgery

BackgroundIntensive care unit (ICU) readmission and unexpected death are closely associated with increased length of hospitalization and total mortality. However, data about readmission or unexpected death after discharge from ICU in patients who have undergone emergency general surgery (EGS) is very limited. MethodsIn total, 1133 patients who underwent EGS were identified in the Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database. Of these 1133 patients, 124 underwent readmission into the ICU or death unexpectedly after their initial discharge. The clinical characteristics of the patients were investigated. A logistic regression model was implemented for the analysis of the independent risk factors associated with ICU readmission or unexpected death. A nomogram model was established to predict the risk of ICU readmission or unexpected death within 72 h after EGS. ResultsPeripheral vascular disease and atrial fibrillation, vasopressor requirement, a higher respiratory rate or heart rate, a lower pulse oxygen saturation or a platelet count of <150 K/μL and a relatively low Glasgow coma scale score in the last 24 h before ICU discharge were independent risk factors for ICU readmission or death within 72 h. The nomogram had moderate accuracy with an area under the curve of 0.852, which had a stronger prediction power than the Stability and Workload Index for Transfer (SWIFT) score, a classic prediction model for ICU readmission risk. ConclusionsIn critically ill patients who undergo EGS, ICU readmission or unexpected death within 72 h can be predicted using a nomogram model based on eight parameters including physiological and laboratory test values in the last 24 h before discharge and comorbidities. ICU physicians should prudently assess patients to make effective discharge decisions.

A National Evaluation of Emergency General Surgery Outcomes Among Hospitalized Cardiac Patients

IntroductionEmergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients. MethodsWe performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non–GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs. ResultsWe identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001). ConclusionsEmergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.

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.

Measuring the Predictive Accuracy of Preoperative Clinical Frailty Instruments Applied to Electronic Health Data in Older Patients Having Emergency General Surgery: A Retrospective Cohort Study.

To compare predictive accuracy of frailty instruments operationalizable in electronic data for prognosticating outcomes among older adults undergoing emergency general surgery (EGS). Older patients undergoing EGS are at higher risk of perioperative morbidity and mortality. Preoperative frailty is a common and strong perioperative risk factor in this population. Despite this, existing barriers preclude routine preoperative frailty assessment. We conducted a retrospective cohort study of adults above 65 undergoing EGS from 2012 to 2018 using Institute for Clinical Evaluative Sciences (ICES) provincial healthcare data in Ontario, Canada. We compared 4 frailty instruments: Frailty Index (FI), Hospital Frailty Risk Score (HFRS), Risk Analysis Index-Administrative (RAI), ACG Frailty-defining diagnoses indicator (ACG). We compared predictive accuracy beyond baseline risk models (age, sex, American Society of Anesthesiologists' score, procedural risk). Predictive performance was measured using discrimination, calibration, explained variance, net reclassification index and Brier score (binary outcomes); using explained variance, root mean squared error and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes were 365-day mortality, nonhome discharge, days alive at home, length of stay, and 30-day and 365-day health systems cost. A total of 121,095 EGS patients met inclusion criteria. Of these, 11,422 (9.4%) experienced death 30 days postoperatively. Addition of FI, HFRS, and RAI to the baseline model led to improved discrimination, net reclassification index, and R2 ; RAI demonstrated the largest improvements. Adding 4 frailty instruments to typically assessed preoperative risk factors demonstrated strong predictive performance in accurately prognosticating perioperative outcomes. These findings can be considered in developing automated risk stratification systems among older EGS patients.

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.