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

Results

Table 1 shows the overall adherence to EGS best practices among all respondents, ranging from 8.5% to 86.2%. The associations between hospital-level characteristics and compliance with EGS patient care best practices and performance improvement best practices on univariate analyses are presented in Table 2 and Table 3, respectively. Nongovernmental ownership was associated with 6 best practices. Urban location was associated with 12 best practices. Teaching status and inpatient bed capacity were associated with 16 best practices each. Medical school affiliation was associated with 15 best practices. Self-reported ACS model adoption was associated with 13 best practices. Trauma certification was associated with 11 of the best practices studied.

Table 4 shows the adjusted odds of adherence to EGS patient care best practices by hospital-level variables not accounting for self-reported adoption of ACS. In terms of guidelines to defer elective cases, no hospital characteristics significantly affected adherence to this best practice. For tiering urgent operations, hospitals with <100 beds, 100 to 199 beds, and 200 to 299 beds compared to ≥500 bed hospitals and hospitals not certified as trauma centers were less likely to adhere. For following National Comprehensive Cancer Network guidelines, hospitals with <100 beds compared to ≥500 bed hospitals and investor-owned compared with nongovernmental hospitals were less likely to adhere. For anticoagulation reversal protocol, hospitals with <100 beds, 100 to 199 beds, and 200 to 299 beds compared to ≥500 bed hospitals and hospitals not certified as trauma centers were less likely to adhere. Odds of being compliant with having transfer agreements to send patients increased with minor and nonteaching compared to major teaching status and hospitals with <100 beds and 100 to 199 beds compared to ≥500 bed hospitals but decreased at hospitals not certified as a trauma center and with investor-owned and governmental ownership compared to nongovernmental ownership. For transfer agreements to receive patients, hospitals with rural compared to urban location, hospitals with <100 beds, 100 to 199 beds, and 200 to 299 beds compared to ≥500 bed hospitals, and hospitals not certified as trauma centers were less likely to adhere. No hospital characteristics significantly affected adherence to an ICU admission protocol, whereas rural compared to urban setting, 100 to 199 beds and <100 beds compared to ≥500 bed hospitals, and being a certified trauma center increased the odds of having an EGS activation system. Finally, odds of having an EGS outpatient clinic decreased with minor compared to major teaching status and all bed sizes compared to ≥500 bed hospitals.

Table 5 shows the odds of adherence to performance improvement processes by hospital-level variables not accounting for self-reported adoption of ACS. For auditing post-op 30-day readmissions and auditing reoperations, hospitals with 100 to 199 beds compared to ≥500 bed hospitals were more likely to adhere. For auditing 30-day return to OR, hospitals with 100 to 199 beds compared to ≥500 bed hospitals were more likely to adhere. No hospital characteristics significantly affected auditing non-op 30-day readmissions, auditing non-op 30-day operations, or auditing returns to the ICU. For monitoring time to surgeon evaluation, hospitals with 100 to 199 beds compared to ≥500 bed hospitals were more likely to be compliant. For monitoring the time to operation start, hospitals with no medical school affiliation and hospitals that were not verified trauma centers were less likely to adhere. For time to source control, hospitals with 300 to 399 beds were more likely to adhere compared to ≥500 bed hospitals. In terms of having an EGS M&M, hospitals with minor teaching or nonteaching status and hospitals that lacked trauma center certification were less likely to adhere. Finally, odds of having an EGS registry decreased when hospitals lacked trauma center certification.

In our study, 94.4% of questionnaire respondents answered whether or not their hospital had implemented an ACS model for EGS care. Among these, 272 hospitals (16.1%) reported, as of 2015, a dedicated clinical team whose scope encompasses EGS (±trauma, ±elective general surgery, ±burns), and 72.5% (N = 1225) reported having a traditional approach with an ad hoc general surgeon on call schedule. Of the 5.8% (N = 99) reporting other, the responses ranged from patients being transferred if a general surgeon was not available, to having one general surgeon on call, to a hybrid model. Figure 2 displays the adjusted and unadjusted odds ratios and confidence intervals for having a formalized ACS model on adherence to EGS best practices when comparing hospitals that have implemented an ACS versus a general surgeon on call approach. Of note, after multivariable adjustment, having implemented ACS was a positive predictor of adherence to 14 out of the 20 best practices.

Figure 2.

Adherence to Emergency General Surgery Best Practices by hospitals with an established Acute Care Surgery model compared to hospitals using a general surgeon on call model. Open circles indicate the unadjusted effect of an established Acute Care Surgery model (vs general surgeon on call approach). Solid black circles indicate the adjusted effect of an established acute care surgery model (vs general surgeon on call model); adjusting effects include geographic region, teaching status, ownership type, inpatient bed capacity, medical school affiliation, and location of the hospital.

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