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


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

In This Article


EGS care fundamentally differs from that provided to elective surgery patients. Unlike elective general surgery patients who can, after diagnosis, improve the severity of some comorbid conditions, mobilize psychosocial support, marshal socioeconomic resources, and plan interventions when hospital resources are at their fullest, EGS patients are stricken suddenly. Although numerous quality improvement efforts have focused on the care of elective surgical patients, healthcare providers and the healthcare system must be prepared to provide high-quality EGS care at a time when the personal and financial burden of healthcare in the United States is growing. As the first national evaluation of adherence to best practices for EGS care, our national questionnaire, with a 60.1% response rate, provides a heretofore undocumented comprehensive assessment of the current state of EGS quality assurance in the United States. Our finding of significant variations in adherence to EGS best practices is concerning and suggests variability in EGS care delivery nationally. We anticipate that, similar to the processes developed for specific patient populations, such as injured[13,18] or bariatric patients,[19] improved compliance with these best practices, through data collection and performance improvement initiatives, would translate into improved outcomes and quality of care. The potential association between compliance with these best practices and improved outcomes represents an area of future investigation that could come from this novel research.

We found that overall adherence to the measures queried in our questionnaire ranged from a low of 8.5% for maintaining a prospective EGS registry to a high of more than 86% for auditing post-op 30-day readmissions. This range could be due to variations in compliance with existing processes for elective procedures that are also applicable to the EGS population. Several of the processes with >50% compliance in our sample (eg, follow National Comprehensive Cancer Network guidelines, post-op 30-day readmissions, audit 30-day return to OR, and audit returns to ICU) appear to have applicability across elective, urgent, and emergent surgical interventions. Therefore, the ease of leveraging resources might be 1 explanation for the relatively high adherence to some practices.[20,21]

On the contrary, resources and practices that would require new workflows, and therefore, potentially more costly or logistically challenging processes, had lower compliance (<50%). These included best practices such as ICU admission protocol, anticoagulant reversal protocol, transfer agreements, EGS activation system, EGS outpatient clinic, time to surgeon evaluation, time to operation start, time to source control, EGS M&M, and EGS registry. One example of a specific process that could be disseminated across EGS care that would increase adherence to one of the best practices (ie, a tiered system to ensure that urgent/emergent operations are started in a timely manner) is utilizing a "traffic-light" coding system to organize emergency surgery.[22] Such interventions decrease night-time surgery, improve the efficiency of operating theatre daytime utilization, and decrease preoperative delay in patients requiring urgent surgery. That these best practices were more likely to be implemented at centers with a declared ACS model suggests that formalizing an overall structure is an important step in developing durable best practices for the vulnerable EGS population. Furthermore, a recent study suggests that such teams may also improve EGS outcomes and reduce costs of care.[23]

We found that the presence of an ACS model of care increased adherence to 14 out of the 20 EGS best practices studied when controlling for other hospital factors, with nonstatistically significant improvement for all other practices with the exception of 30-day return to OR. Although our previous research has demonstrated that the ACS model of EGS care is resource intensive and is thus potentially less likely to be implemented at smaller, nonacademic hospitals,[24] this does not negate the importance of identifying and establishing best practices for EGS care for all hospital settings in which a patient with a nontraumatic surgical emergency may present. Similar to the guidelines that have been established and are uniformly applied to level I, II, and III trauma centers, a core set of EGS best practices could be established for all acute care hospitals that care for nontraumatic surgical emergencies in the United States. If a hospital cannot meet these core expectations, a systematic approach to the triage and transfer of EGS patients may be necessary to ensure quality EGS care and to provide adequate support to providers working in less-resourced environments. Our results show that lack of trauma certification significantly decreased the odds of compliance with 8 of the 20 best practices studied. The increased compliance observed for the 8 best practices by hospitals with trauma certification may indicate that patients with nontraumatic surgical emergencies are benefiting indirectly from the resources these hospitals have already committed to caring for injured patients. Given the existing workforce issues in surgery and increasing closures of ERs and hospitals in more rural areas of the United States, a regionalized system drawing upon the lessons learned from stroke care, neonatal intensive care, acute coronary syndrome care, and trauma care may optimize access and quality for EGS patients. Although it is not sustainable for all nontraumatic surgical emergencies to be transferred to a higher level of care from patient, provider, or healthcare system vantages, facilitating the transfer of appropriate patients to tertiary care centers while simultaneously optimizing the care at rural and community hospitals who retain EGS patients would appear to be one reasonable strategy to improve EGS care for all patients.

There are several limitations to this study. Although a 60% response rate is laudable for survey research, especially among physicians,[25] 40% of hospitals where an adult with a nontrauma surgical emergency might seek care were not represented. Our comparison of responders to nonresponders showed that responders were more likely to represent large, nonprofit hospitals with a teaching affiliation (see on-line Appendix 3,; therefore, our results may not be generalizable to smaller, governmental, or for-profit hospitals without a teaching affiliation. Second, a limitation of any survey is that the information is only as reliable as the individual who is completing the survey. Targeted efforts were made to ensure that the individual completing the survey was the individual most knowledgeable of the care provided to EGS patients at his/her respective institution and what, if any, degree of compliance existed at his/her hospital in terms of the best practices queried for this manuscript. Third, we relied on self-report for determining whether or not a hospital was utilizing an ACS model. We presumed that the individual completing the survey appropriately represented whether or not his/her hospital delivered EGS care using an ACS model. Importantly, due to Health Insurance Portability and Accountability Act requirements and the research ethics applied to our survey administration, hospitals were deidentified before analyzing survey responses; therefore, we cannot determine which hospitals in our survey had ACS fellowships or report on their performance compared to those without ACS fellowships. It would be anticipated that the 20 US hospitals known to have ACS fellowships accredited by the American Association for the Surgery of Trauma would perform higher in terms of our outcome measures but we are unable to address this question directly in our research. Given that there are no verification criteria to date for establishing ACS programs and that we relied on self-report to determine whether an ACS model was being utilized, our results may be subject to misclassification bias. Finally, the best practices measured have not, to our knowledge, been linked to outcome improvements. It is possible that, despite our use of robust appropriateness methodology, qualitative data, and pilot testing, we may not have captured all aspects important to the delivery of high-quality EGS care. However, a strength of this work is that it is based, in part, on quality indicators that were developed utilizing a modification of the RAND Appropriateness Methodology, a Delphi technique that has been demonstrated to yield appropriateness criteria and quality indicators that have face, construct, and predictive validity.[26–31]

Despite these limitations, our research provides a starting point, from a national perspective, on how EGS care may benefit from hospitals and health care providers measuring and improving their compliance with quality indicators, similar to that which has been accomplished for care provided to patients diagnosed with cancer, injury, and stroke.[13,27,32–34] Quality improvement efforts for nonemergent surgical conditions have included evaluation of risk-adjusted outcomes, regionalization of care to "centers of excellence," and development of specific process measures.[27] For example, hospitals within Commission on Cancer-approved cancer programs report data based upon quality measures for cancer care to the National Cancer Database. Hospitals are then provided with quality of care reports allowing for comparison of their performance on each measure relative to the other Commission on Cancer hospitals.[32] A similar structure does not currently exist for EGS care. Linking adherence to these best practices to actual patient outcomes will provide additional evidence as to the key structures and processes necessary to deliver high-quality EGS care.

Given the vulnerability of EGS patients to complications, readmissions, and death and the increased emphasis in the healthcare system on cost-containment and accountability, addressing the variability in compliance may serve as the next logical step to improving EGS care. As policymakers, quality officers, and healthcare providers embark on quality improvement efforts targeting EGS care, they should carefully consider the hospital-level structures and processes that make compliance to EGS-specific best practices possible and how regulatory programs might best measure quality indicators prospectively.[35]