Adherence to 20 Emergency General Surgery Best Practices

Results of a National Survey

Angela M. Ingraham, MD, MS; M. Didem Ayturk, MS; Catarina I. Kiefe, MD, PhD; Heena P. Santry, MD, MS

Disclosures

Annals of Surgery. 2019;270(2):270-280. 

In This Article

Abstract and Introduction

Abstract

Objective: To examine national adherence to emergency general surgery (EGS) best practices.

Background: There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data.

Method: A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression.

Results: The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries.

Conclusions: There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.

Introduction

The substantial incidence and burden of emergency general surgery (EGS) care combined with a shortage of general surgeons have set the stage for a "looming catastrophe" in public health.[1,2] More than 3 million patients are admitted to US hospitals annually for EGS diseases (eg, perforated viscus, appendicitis, cholecystitis).[3] Indeed, the annual case rate (1290 per 100,000) is higher than the sum of all new cancer diagnoses (all ages/types: 650 per 100,000).

EGS carries with it significant morbidity, mortality, and cost.[4,5] When comparing emergent and elective general surgery procedures in the American College of Surgeons National Surgical Quality Improvement Program, emergency surgery was an independent risk factor for mortality and postoperative complications.[4] Mortality was 13% for EGS patients and 3% for elective surgical patients. Major complications occurred in 33% of EGS patients and 13% of elective surgical patients. Controlling for preoperative variables and procedure type, emergency surgery increased the odds of death by 40% and of major complications by 30%. In addition to causing physical harm, the financial burden of EGS diseases to patients and society is high. The cost of EGS hospitalizations in 2010 was $28.4 billion and is projected to increase to $41.2 billion in 2060.[5]

Despite the high volume and significant patient- and system-level costs, a public health focus on and quality improvement efforts dedicated to EGS care are lacking.[3] The development of acute care surgery (ACS), an evolving specialty uniting trauma, EGS, and critical care, has underscored the growing crisis in access to timely, high-quality care for nontraumatic surgical emergencies.[6,7] With the evolution of ACS, the process and performance improvement initiatives that have guided trauma care over the last 6 decades are slowly being applied to EGS care.

Such improvement initiatives have resulted in an 8% to 9% decrease in mortality following injury and could serve as a model to improve EGS care under the ACS umbrella.[8–12] However, a critical component of the trauma system, guidelines to direct care established by the American College of Surgeons Committee on Trauma and various state-level regulatory agencies, is not well-established for EGS.[13] Furthermore, nationwide adherence to the limited number of indicators that are available is unknown. With a scarce number of guidelines and best practices specific to EGS, hospitals and healthcare providers have few standards to reference as they provide care for EGS patients. Our objective in this study was to examine adherence to 20 select EGS quality indicators and best practices among a national sample of acute care hospitals.

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