Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective.

ABSTRACT: The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the healthcare system - the patient, the healthcare organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.

Extracorporeal Membrane Oxygenation During Surgical Stabilization of Rib Fractures in Successful Management of Severe Blunt Chest Trauma.

Early surgical stabilization of rib fracture (SSRF) improves outcomes in patients with flail physiology and severely displaced fractures. We present two cases of patients with severe chest injury and large flail segment who underwent SSRF while on veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patients developed respiratory failure within 24 hours of admission requiring VV-ECMO. The extent of their chest wall injury limited pulmonary mechanics prohibiting transition off VV-ECMO. Therefore, SSRF was performed on hospital days 2 and 3 and while on VV-ECMO support. Stabilizing the chest wall allowed for improved ventilation and successful decannulation from VV-ECMO on postoperative days 3 and 4. Ultimately, both achieved a functional recovery and were discharged home. These cases demonstrate a unique thoracic damage control strategy wherein SSRF is performed while on VV-ECMO. Improving chest stability and pulmonary mechanics with SSRF allowed for safe transition off VV-ECMO and achieved a favorable long-term outcome.

Early warning: End-tidal carbon dioxide is associated with central venous oxygenation under continuous cardiorespiratory monitoring in a porcine model of hemorrhagic shock and resuscitation.

BACKGROUND: End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS: A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N â€‹= â€‹7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS: Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (ߠ​= â€‹1.783, 95% confidence interval (CI) [1.552-2.014], p â€‹< â€‹0.001) and during the period of most rapid hemorrhage (ߠ​= â€‹4.896, 95% CI [2.416-7.377], p â€‹< â€‹0.001) when there was a marked decrease in ETCO2. CONCLUSIONS: ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

Implementation of a Gastrografin Order Set for Small Bowel Obstruction Across a Health System: A Cohort Study.

BACKGROUND: The use of Gastrografin (GG) in the management of adhesive small bowel obstruction (SBO) has been shown to decrease the length of stay and operative intervention. METHODS: This retrospective cohort study examined patients with an SBO diagnosis prior to implementation (PRE, January 2017-January 2019) and following implementation (POST, January 2019-May 2021) of a GG challenge order set made available across 9 hospitals within a health care system. Primary outcomes were utilization of the order set across facilities and over time. Secondary outcomes included time to surgery for operative patients, rate of surgery, nonoperative length of stay, and 30-day readmission. Standard descriptive, univariate, and multivariable regression analyses were performed. RESULTS: PRE cohort had 1746 patients and POST had 1889. The utilization of GG increased from 14% to 49.5% following implementation. Significant variability existed within the hospital system with utilization at each individual hospital from 11.5% to 60%. There was an increase in surgical intervention (13.9% vs 16.4%, P = .04) and decrease in nonoperative LOS (65.6 vs 59.9 hours, P < .001) following implementation. For POST patients, multivariable linear regression showed significant reduction in nonoperative length of stay (-23.1 hours, P < .001) but no significant difference in time to surgery (-19.6 hours, P = .08). DISCUSSION: The availability of a standardized order set for SBO can result in increased Gastrografin administration across hospital settings. The implementation of a Gastrografin order set was associated with decreased length of stay in nonoperative patients.

Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days.

BACKGROUND: Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). METHODS: SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. RESULTS: 241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). CONCLUSION: Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.

TQIP mortality reporting system case reports: Unanticipated mortality due to inadequate preoperative ICU "clearance".

ABSTRACT: The Trauma Quality Improvement Program Mortality Reporting System is an online anonymous case reporting system designed to share experiences from rare events that may have contributed to unanticipated mortality at contributing trauma centers. The Trauma Quality Improvement Program Mortality Reporting System Working Group monitors submitted cases and organizes them into emblematic themes. This report summarizes unanticipated mortality from a case of inadequate clearance by the intensive care unit service before surgical intervention in an injured patient and presents strategies to mitigate these events locally with the hope of decreasing unanticipated mortality nationwide.

Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center.

BACKGROUND: Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. METHODS: We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. RESULTS: Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). CONCLUSIONS: EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.

Impact of COVID-19 on common non-elective general surgery diagnoses.

BACKGROUND: During the COVID-19 pandemic, public health and hospital policies were enacted to decrease virus transmission and increase hospital capacity. Our aim was to understand the association between COVID-19 positivity rates and patient presentation with EGS diagnoses during the COVID pandemic compared to historical controls. METHODS: In this cohort study, we identified patients ≥ 18 years who presented to an urgent care, freestanding ED, or acute care hospital in a regional health system with selected EGS diagnoses during the pandemic (March 17, 2020 to February 17, 2021) and compared them to a pre-pandemic cohort (March 17, 2019 to February 17, 2020). Outcomes of interest were number of EGS-related visits per month, length of stay (LOS), 30-day mortality and 30-day readmission. RESULTS: There were 7908 patients in the pre-pandemic and 6771 in the pandemic cohort. The most common diagnoses in both were diverticulitis (29.6%), small bowel obstruction (28.8%), and appendicitis (20.8%). The lowest relative volume of EGS patients was seen in the first two months of the pandemic period (29% and 40% decrease). A higher percentage of patients were managed at a freestanding ED (9.6% vs. 8.1%) and patients who were admitted were more likely to be managed at a smaller hospital during the pandemic. Rates of surgical intervention were not different. There was no difference in use of ICU, ventilator requirement, or LOS. Higher 30-day readmission and lower 30-day mortality were seen in the pandemic cohort. CONCLUSIONS: In the setting of the COVID pandemic, there was a decrease in visits with EGS diagnoses. The increase in visits managed at freestanding ED may reflect resources dedicated to supporting outpatient non-operative management and lack of bed availability during COVID surges. There was no evidence of a rebound in EGS case volume or substantial increase in severity of disease after a surge declined.

Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients.

BACKGROUND/OBJECTIVES: Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. METHODS: Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. RESULTS: Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. CONCLUSION: Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

Just What the Doctor Ordered: Missed Ordering of Venous Thromboembolism Chemoprophylaxis Is Associated With Increased VTE Events in High-risk General Surgery Patients.

OBJECTIVE: To define the impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations. BACKGROUND: The primary cause of preventable death in surgical patients is VTE. Although guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing. METHODS: All adult inpatients who underwent a general surgery procedure between 2016 and 2019 and were entered into Atrium Health National Surgical Quality Improvement Program registry were identified. Patients at high risk for VTE (2010 Caprini score ≥5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. Electronic medical record identified compliance with "perfect" VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events. RESULTS: A total of 19,578 patients were identified of which 4252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay and lower perioperative red blood cell transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (odds ratio: 0.50; 95% CI, 0.30-0.80) and 55% reduction in VTE event/mortality (odds ratio: 0.45; 95% CI, 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality. CONCLUSIONS: pVTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.

Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury.

BACKGROUND: The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury. METHODS: A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h. RESULTS: There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021). CONCLUSION: Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center.

BACKGROUND: The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints. METHODS: An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality. RESULTS: There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively. CONCLUSION: Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

The physiology of failure: Identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record.

BACKGROUND: Emergency general surgery (EGS) patients have increased mortality risk compared with elective counterparts. Recent studies on risk factors have largely used national data sets limited to administrative data. Our aim was to examine risk factors in an integrated regional health system EGS database, including clinical and administrative data, hypothesizing that this novel process would identify clinical variables as important risk factors for mortality. METHODS: Our nine-hospital health system's billing data were queried for EGS International Classification of Disease codes between 2013 and 2018. Codes were grouped by diagnosis, and urgent or emergent encounters were included and merged with electronic medical record clinical data. Outcomes assessed were inpatient and 1-year mortality. Standard and multivariable statistics evaluated factors associated with mortality. RESULTS: There were 253,331 EGS admissions with 3.6% inpatient mortality rate. Patients who suffered inpatient and 1-year mortality were older, more likely to be underweight, and have neutropenia or elevated lactate. On multivariable analysis for inpatient mortality: age (odds ratio [OR], 1.7-6.7), underweight body mass index (OR, 1.6), transfer admission (OR, 1.8), leukopenia (OR, 2.0), elevated lactate (OR, 1.8), and ventilator requirement (OR, 7.1) remained associated with increased risk. Adjusted analysis for 1-year mortality demonstrated similar findings, with highest risk associated with older age (OR, 2.8-14.6), underweight body mass index (OR, 2.3), neutropenia (OR, 2.0), and tachycardia (OR, 1.7). CONCLUSION: After controlling for patient and disease characteristics available in administrative databases, clinical variables remained significantly associated with mortality. This novel yet simple process allows for easy identification of clinical data points imperative to the study of EGS diagnoses that are critical in understanding factors that impact mortality. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Emergency General Surgery Transfer and Effect on Inpatient Mortality and Post-Discharge Emergency Department Visits: A Propensity Score Matched Analysis.

BACKGROUND: Patients undergoing emergency general surgery (EGS) and interhospital transfer (IHT) have increased mortality. Prior analyses of IHT have been limited by the inability to track post-discharge outcomes or have not included nonoperative EGS. We evaluated outcomes for IHT to our tertiary care facility compared with direct admission through the emergency department. STUDY DESIGN: Patients admitted directly (2015 to 2017) with a common EGS diagnosis (appendicitis, cholecystitis, choledocholithiasis, small bowel obstruction, and diverticulitis) were propensity score matched to patients transferred from another acute care hospital. Propensity score matching (PSM) was performed using patient characteristics, EGS diagnosis, comorbidities, and surgical critical care consultation. The primary outcome was inpatient mortality, and secondary outcomes were length of stay (LOS) 30-day hospital readmission. RESULTS: We identified 3,153 directly admitted patients and 1,272 IHT patients. IHT patients were older (mean 59.4 vs 51.5 years), had a higher Charlson comorbidity index (median 3 vs 1), White race (72% vs 49%), and BMI greater than 40 kg/m2 (11.6% vs 9.8%). After PSM, each group included 1,033 patients. IHT patients had a higher median LOS (5.5 days vs 3.8, p < 0.001), higher inpatient mortality (odds ratio [OR] 1.69, p = 0.03), and more complications (OR 1.57, p < 0.001). The rate of post-discharge 30-day hospital encounters was similar (OR 1.08, p = 0.460). However, IHT patients had more emergency department encounters (OR 1.35, p = 0.04) and fewer observation-status readmissions (OR 0.53, p = 0.01). CONCLUSIONS: After PSM to reduce confounding variables, patients with common EGS diagnoses transferred to a tertiary care facility have increased inpatient morbidity and mortality. The increased morbidity and resource utilization for these patients extends beyond the index hospital stay.

Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues.

Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.

Attention to detail: A dedicated rib fracture consultation service leads to earlier operation and improved clinical outcomes.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes. METHODS: A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge. RESULTS: 1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days. CONCLUSION: Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted. LEVEL OF EVIDENCE: III.

Value in acute care surgery, Part 1: Methods of quantifying cost.

BACKGROUND: With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.