Translating the Value of the Academic Surgeon Into Salary, Time, and Resources.

Academic surgeons provide tremendous value to institutions including notoriety, publicity, cutting-edge clinical advances, extramural funding, and academic growth and development. In turn, these attributes may result in improved reputation scores and hospital or medical center rankings. While many hospital systems, schools of medicine, and departments of surgery claim to have a major commitment to academic surgery and research, academic surgeons are often undercompensated compared to clinically focused counterparts. Existing salary benchmarks (e.g., the Medical Group Management Association (MGMA) or the Association of American Medical Colleges (AAMC)) are often used but are imperfect. Thus, the value proposition for academic surgeons goes beyond compensation and often includes protected time for academic pursuit, nonsalary financial support, and other intangible benefits to being associated with a major academic center (e.g., abundance of scientific collaborators, infrastructure for grant management). As a result, institution-specific practices have developed and academic surgeons are left to negotiate salary support including bonus structures, protected time, and recruitment packages on a case-by-case basis without a clear roadmap. A diverse panel representing a range of academic surgical experiences was convened at the 2022 Academic Surgical Congress to illuminate this complex, often stress-inducing, aspect of an academic surgeon's professional career.

The invisible work of transfer centre nurses: A qualitative study of strategies to overcome communication challenges.

AIMS: To explore the role of transfer centre nurses and how they facilitate communication between referring and accepting providers during calls about interhospital transfers, including their strategies to overcome communication challenges. DESIGN: A qualitative interview study. METHODS: We conducted semi-structured interviews with 17 transfer centre nurses at one tertiary medical centre from March to August 2019, asking participants to describe their work. We performed content analysis, applying codes based on the Relational Coordination Framework and generating emergent codes, then organized codes in higher-order concepts. We followed the COREQ checklist. RESULTS: Transfer centre nurses employed multiple strategies to mitigate communication challenges. When referring providers had misconceptions about the transfer centre nurse's role and the accepting hospital's processes, the nurses informed referring providers why sharing information with them was necessary. If providers expressed frustrations or lacked understanding about their counterpart's caseload, the nurses managed providers' emotions by letting them "vent," explaining the other provider's situational context and describing the hospital's capabilities. Some nurses also mediated conflict and sought to break the tension if providers debated about the best course of action. When providers struggled to share complete and accurate information, the nurses hunted down details and 'filled in the blanks'. CONCLUSION: Transfer centre nurses perform invisible work throughout the lifespan of interhospital transfers. Nurses' expert knowledge of the transfer process and hospitals' capabilities can enhance provider communication. Meanwhile, providers' lack of knowledge of the nurse's role can impede respectful and efficient transfer conversations. Interventions to support and optimize the transfer centre nurses' critical work are needed. IMPACT: This study describes how transfer centre nurses facilitate communication and overcome challenges during calls about interhospital transfers. An intervention that supports this critical work has the potential to benefit nurses, providers and patients by ensuring accurate and complete information exchange in an effective, efficient manner that respects all parties. PATIENT OR PUBLIC CONTRIBUTION: This study was designed to capture the perspectives and experiences of transfer centre nurses themselves through interviews. Therefore, it was not conducted using input or suggestions from the public or the patient population served by the organization.

Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen.

BACKGROUND: Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans. METHODS: Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. RESULTS: We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). CONCLUSIONS: Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach.

BACKGROUND: Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS: We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS: Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION: Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS: Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Adherence to 20 Emergency General Surgery Best Practices: Results of a National Survey.

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.

Characteristics and Timing of Interhospital Transfers of Emergency General Surgery Patients.

BACKGROUND: Transferred emergency general surgery (EGS) patients have increased morbidity, mortality, and costs, yet little is known about the characteristics of such transfers. Increasing specialization and a decreasing general surgery workforce have led to concerns about access to care, which may lead to increased transfers. We sought to evaluate the reasons for and timing of transfers for EGS diagnoses. METHODS: We performed a retrospective medical record review of patients transferred to a tertiary academic medical center between January 4, 2014 and March 31, 2016 who had an EGS diagnosis (bowel obstruction, appendicitis, cholecystitis/cholangitis/choledocholithiasis, diverticulitis, mesenteric ischemia, perforated viscus, or postoperative surgical complication). RESULTS: Three hundred thirty-four patients were transferred from 70 hospitals. Transfer reasons varied with the majority due to the need for specialized services (44.3%) or a surgeon (26.6%). Imaging was performed in 95.8% and 35.3% had surgeon contact before transfer. The percentage of patients who underwent procedures at referring facilities was 7.5% (n = 25), while 60.6% (n = 83) underwent procedures following transfer. Mean time between transfer request and arrival at the accepting hospital was lower for patients who subsequently underwent a procedure at the accepting hospital compared to those who did not for patients originating in emergency departments (2.6 versus 3.4 h, P < 0.05) and inpatient units (6.9 versus 14.3 h, P < 0.05). CONCLUSIONS: Interhospital transfers for EGS conditions are frequently motivated by a need for a higher level of care or specialized services as well as a need for a general surgeon. Understanding reasons for transfers can inform decisions regarding the allocation and provision of care for this vulnerable population.

Variations in the Delivery of Emergency General Surgery Care in the Era of Acute Care Surgery.

BACKGROUND: Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use. METHODS: A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital. RESULTS: Survey response was 60.1% (n = 1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS-specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p < 0.0001). CONCLUSION: There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care.

Patient-Centered Outcome Spectrum: An Evidence-based Framework to Aid in Shared Decision-making.

OBJECTIVE: Our objective was to develop an alternate construct for reporting anticipated outcomes after emergency general surgery (EGS) that presents risk in terms of a composite measure. BACKGROUND: Currently available prediction tools generate risk outputs for discrete as opposed to composite measures of postoperative outcomes. A construct to synthesize multiple discrete estimates into a global understanding of a patient's likely postoperative health status is lacking and could augment shared decision-making conversations. METHODS: Using the 2012 to 2014 American College of Surgeons National Surgical Quality Improvement Program Participant Use File, we developed the Patient-Centered Outcomes Spectrum (PCOS) for patients ≥65 years old who underwent an EGS operation. The PCOS defines 3 exclusive types of global outcomes (good, intermediate, and bad outcomes) and allows patients to be prospectively stratified by both their EGS diagnosis and preoperative surgical risk profile. RESULTS: Of the patients in our study population, 13,330 (46.4%) experienced a 30-day postoperative course considered a good outcome. Conversely, 3791 (13.2%) of study patients experienced a bad outcome. The remainder of patients (11,617; 40.4%) were classified as experiencing an intermediate outcome. The incidence of good, intermediate, and bad outcomes was 69.7%, 28.2%, and 2.1% for low-risk patients, and 22.0%, 48.9%, and 29.1% for high-risk patients. Diagnosis-specific PCOS constructs are also provided. CONCLUSIONS: Consistent with the goals of shared decision-making, the PCOS provides an evidence-based construct based upon a composite outcome measure for patients and providers as they weigh the risks of undergoing EGS.

Assessing written communication during interhospital transfers of emergency general surgery patients.

BACKGROUND: Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities. METHODS: We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated. RESULTS: A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided. CONCLUSIONS: This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers.

Effect of transfer status on outcomes for necrotizing soft tissue infections.

BACKGROUND: Whether patients with necrotizing soft tissue infections (NSTI) who presented to under-resourced hospitals are best served by immediate debridement or expedited transfer is unknown. We examined whether interhospital transfer status impacts outcomes of patients requiring emergency debridement for NSTI. METHODS AND MATERIALS: We conducted a retrospective review studying patients with an operative diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene in the 2010-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. Multivariable regression analyses determined if transfer status independently predicted 30-d mortality, major morbidity, minor morbidity, and length of stay. RESULTS: Among 1801 patients, 1243 (69.0%) were in the non-transfer group and 558 (31.0%) were in the transfer group. The transfer group experienced higher rates of 30-d mortality (14.5% versus 13.0%) and major morbidity (64.5% versus 60.1%) than the non-transfer group, which were not significant after risk adjustment (adjusted odds ratio [95% confidence interval]: 0.87 [0.62-1.22] and 1.00 [0.79-1.27], respectively). The transferred group experienced a longer median length of postoperative hospitalization (14 d [interquartile range 8-24] versus 11 d [6-20]), which maintained statistical significance after adjustment for other factors (adjusted beta coefficient [95% confidence interval]: 1.92 [0.48-3.37]; P = 0.009). CONCLUSIONS: Our results suggest that interhospital transfer status is not an independent risk factor for mortality or morbidity after surgical management of NSTI. Although expedient debridement remains a basic tenet of NSTI management, our findings provide some reassurance that transfer before initial debridement will not significantly jeopardize patient outcomes should such transfer be deemed necessary.

Greater patient sharing between hospitals is associated with better outcomes for transferred emergency general surgery patients.

BACKGROUND: Access to emergency surgical care has declined as the rural workforce has decreased. Interhospital transfers of patients are increasingly necessary, and care coordination across settings is critical to quality care. We characterize the role of repeated hospital patient sharing in outcomes of transfers for emergency general surgery (EGS) patients. METHODS: A multicenter study of Wisconsin inpatient acute care hospital stays that involved transfer of EGS patients using data from the Wisconsin Hospital Association, a statewide hospital discharge census for 2016 to 2018. We hypothesized that higher proportion of patients transferred between hospitals would result in better outcomes. We examined the association between the proportion of EGS patients transferred between hospitals and patient outcomes, including in-hospital morbidity, mortality, and length of stay. Additional variables included hospital organizational characteristics and patient sociodemographic and clinical characteristics. RESULTS: One hundred eighteen hospitals transferred 3,197 emergency general surgery patients over the 2-year study period; 1,131 experienced in-hospital morbidity, mortality, or extended length of stay (>75th percentile). Patients were 62 years old on average, 50% were female, and 5% were non-White. In the mixed-effects model, hospitals' proportion of patients shared was associated with lower odds of an in-hospital complication; specifically, when the proportion of patients shared between two hospitals doubled, the relative odds of any outcome changed by 0.85. CONCLUSION: Our results suggest the importance of emergent relationships between hospital dyads that share patients in quality outcomes. Transfer protocols should account for established efficiencies, familiarity, and coordination between hospitals. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Quality of Care for Gallstone Pancreatitis-the Impact of the Acute Care Surgery Model and Hospital-Level Operative Resources.

BACKGROUND: Index cholecystectomy is the standard of care for gallstone pancreatitis. Hospital-level operative resources and implementation of an acute care surgery (ACS) model may impact the ability to perform index cholecystectomy. We aimed to determine the influence of structure and process measures related to operating room access on achieving index cholecystectomy for gallstone pancreatitis. METHODS: In 2015, we surveyed 2811 US hospitals on ACS practices, including infrastructure for operative access. A total of 1690 hospitals (60%) responded. We anonymously linked survey data to 2015 State Inpatient Databases from 17 states using American Hospital Association identifiers. We identified patients ≥ 18 years who were admitted with gallstone pancreatitis. Patients transferred from another facility were excluded. Univariate and multivariable regression analyses, clustered by hospital and adjusted for patient factors, were performed to examine multiple structure and process variables related to achieving an index cholecystectomy rate of ≥ 75% (high performers). RESULTS: Over the study period, 5656 patients were admitted with gallstone pancreatitis and 70% had an index cholecystectomy. High-performing hospitals achieved an index cholecystectomy rate of 84.1% compared to 58.5% at low-performing hospitals. On multivariable regression analysis, only teaching vs. non-teaching hospital (OR 2.91, 95% CI 1.11-7.70) and access to dedicated, daytime operative resources (i.e., block time) vs. no/little access (OR 1.93, 95% CI 1.11-3.37) were associated with high-performing hospitals. CONCLUSIONS: Access to dedicated, daytime operative resources is associated with high quality of care for gallstone pancreatitis. Health systems should consider the addition of dedicated, daytime operative resources for acute care surgery service lines to improve patient care.

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.

The importance of assessing both inpatient and outpatient surgical quality.

OBJECTIVE: We aimed to determine whether hospital-level surgical performance was similar across outpatient and inpatient settings. BACKGROUND: The majority of surgical procedures in the United States are performed in an outpatient setting but most quality improvement focuses on inpatient care. METHODS: Using data from the 2006 to 2008 American College of Surgeons- National Surgical Quality Improvement Program, risk-adjusted hospital observed to expected ratios for morbidity and mortality were compared for inpatient and outpatient cases. In addition, hospital outpatient performance in each year was compared with performances in subsequent years. RESULTS: Hospitals demonstrated variation in outcomes for outpatient morbidity with both good and poor outliers in each year. Outpatient mortality was so rare as to not support robust modeling. There was a lack of congruence between hospital performance for outpatient morbidity and either inpatient morbidity or inpatient mortality in each year, indicating that inpatient performance is not interchangeable with outpatient performance. Outpatient morbidity performance correlation between years was only moderate (correlations 0.449-0.534, all P < 0.001) indicating that although outcomes from 1 year mildly predict subsequent years, substitution of data would likely lead to missed opportunities for improvement. CONCLUSIONS: Assessments of risk-adjusted hospital-level outpatient morbidity performance demonstrate (1) variability across American College of Surgeons- National Surgical Quality Improvement Program sites; (2) a lack of congruence between outpatient morbidity performance and either inpatient morbidity or mortality performance; (3) year-to-year variation of outpatient morbidity performance at individual institutions. Continuing evaluation of both outpatient and inpatient outcomes is supported. Given the substantial volume of outpatient care delivered, outpatient assessments are likely to be an important component of ongoing quality improvement efforts.

The role of Surgical Champions in the American College of Surgeons National Surgical Quality Improvement Program--a national survey.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) empowers surgeons and medical centers to reliably collect, analyze, and act on clinically collected outcomes data. How individual ACS NSQIP leaders designated as Surgeon Champions (SC) utilize the ACS NSQIP at the hospital level and the obstacles they encounter are not well studied. MATERIALS AND METHODS: All SC representing the 236 hospitals participating in the ACS NSIQP were invited to complete a survey designed to assess the role of the SC, data use, continuous quality improvement (CQI) efforts, CQI culture, and financial implications. RESULTS: We received responses from 109 (46.2%) SC. The majority (72.5%) of SC were not compensated for their CQI efforts. Factors associated with demonstrable CQI efforts included longer duration of participation in the program, frequent meetings with clinical reviewers, frequent presentation of data to administration, compensation for Surgical Champion efforts and providing individual surgeons with feedback (all P < 0.05). Almost all SC stated ACS NSQIP data improved the quality of care that patients received at the hospital level (92.4%) and that the ACS NSQIP provided data that could not be obtained by other sources (95.2%). All SCs considered future funding for participation in the ACS NSQIP secure. CONCLUSIONS: Active use of ACS NSQIP data provide SC with demonstrable CQI by regularly reviewing data, having frequent interaction with clinical reviewers, and frequently sharing data with hospital administration and colleagues. SC thus play a key role in successful quality improvement at the hospital level.

Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis.

BACKGROUND: Informed consent is an ethical and legal requirement that differs from informed decision-making-a collaborative process that fosters participation and provides information to help patients reach treatment decisions. The objective of this study was to measure informed consent and informed decision-making before major surgery. STUDY DESIGN: We audio-recorded 90 preoperative patient-surgeon conversations before major cardiothoracic, vascular, oncologic, and neurosurgical procedures at 3 centers in the US and Canada. Transcripts were scored for 11 elements of informed consent based on the American College of Surgeons' definition and 9 elements of informed decision-making using Braddock's validated scale. Uni- and bivariate analyses tested associations between decision outcomes as well as patient, consultation, and surgeon characteristics. RESULTS: Overall, surgeons discussed more elements of informed consent than informed decision-making. They most frequently described the nature of the illness, the operation, and potential complications, but were less likely to assess patient understanding. When a final treatment decision was deferred, surgeons were more likely to discuss elements of informed decision-making focusing on uncertainty (50% vs 15%, p = 0.006) and treatment alternatives (63% vs 27%, p = 0.02). Conversely, when surgery was scheduled, surgeons completed more elements of informed consent. These results were not associated with the presence of family, history of previous surgery, location, or surgeon specialty. CONCLUSIONS: Surgeons routinely discuss components of informed consent with patients before high-risk surgery. However, surgeons often fail to review elements unique to informed decision-making, such as the patients' role in the decision, their daily life, uncertainty, understanding, or patient preference.

Gaps in Emergency General Surgery Coverage in the United States.

INTRODUCTION: Despite three million adults in the United States (US) being admitted annually for emergency general surgery (EGS) conditions, which disproportionately affect vulnerable populations, we lack an understanding of the barriers to round-the-clock EGS care. Our objective was to measure gaps in round-the-clock EGS care. METHODS: From August 2015 to December 2015, we surveyed all US-based, adult acute care general hospitals that have an emergency room and ≥1 operating room and provide EGS care, utilizing paper and electronic methods. Surgeons or chief medical officers were queried regarding EGS practices. RESULTS: Of 2,811 hospitals, 1,634 (58.1%) responded; 279 (17.1%) were unable to always provide round-the-clock EGS care. Rural location, smaller bed size, and non-teaching status were associated with lack of round-the-clock care. Inconsistent surgeon coverage was the primary reason for lacking round-the-clock EGS care (n=162; 58.1%). However, lack of a tiered system for booking emergency cases, no anesthesia availability overnight, and no stipend for EGS call were also associated with the inability to provide round-the-clock EGS care. DISCUSSION: We found significant gaps in access to EGS care, often attributable to workforce deficiencies.

Re-examining "Never Letting the Sun Rise or Set on a Bowel Obstruction" in the Era of Acute Care Surgery.

BACKGROUND: Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes. METHODS: Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured. RESULTS: Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced more systemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83-0.99]) and defer elective cases (aOR 0.87 [0.80-0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04-1.26]) or rarely/never (aOR 1.16 [1.06-1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6-2.4]), operative complication (OR 1.5 [1.2-1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7-4.0]). CONCLUSIONS: Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.

In-house intensivist presence does not affect mortality in select emergency general surgery patients.

BACKGROUND: This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. METHODS: Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. RESULTS: We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. CONCLUSION: Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. LEVEL OF EVIDENCE: Therapeutic, level III.

Effect of postdischarge morbidity and mortality on comparisons of hospital surgical quality.

BACKGROUND: Hospitals increasingly rely on surgical quality assessment programs that require considerable resources to capture outcomes after hospital discharge. However, it is unclear whether capturing postdischarge complications and deaths is important. Our objectives were (1) to determine the frequency of postdischarge complications and deaths and (2) to determine whether hospital rankings change with inclusion of postdischarge outcomes. METHODS: From 181 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program, 329,951 patients were identified (2006-2007). Mortality and 19 complications within 30 days of the index operation were categorized as occurring before or after discharge. Risk-adjusted hospital rankings were compared based on whether only predischarge (inpatient) versus both pre- and postdischarge (inpatient and outpatient within 30 days of operation) morbidity and mortality were included. RESULTS: Postdischarge complications accounted for 32.9% of all complications. Certain complications occurred frequently after discharge: surgical site infections (66.0%), urinary tract infections (39.4%), pulmonary embolisms (42.2%), and deep venous thromboses (34.5%). Of all patients experiencing complications, 39.7% had only postdischarge complications. Of 5827 postoperative deaths, 23.6% occurred after discharge. Hospital quality rankings changed when postdischarge outcomes were excluded versus included for morbidity (median hospital rank change: 16 ranks; interquartile range, 7-36) and mortality (median hospital rank change: 14 ranks; interquartile range, 6-29), and there was disagreement in outlier status designations depending on whether postdischarge events were included (morbidity: kappa = 0.546; mortality: kappa = 0.507). CONCLUSIONS: A substantial proportion of postoperative complications and deaths occur after hospital discharge. Inclusion of postdischarge events considerably affects hospital quality rankings and outlier status designations. Quality improvement programs and research that do not consider postdischarge outcomes may offer incomplete information to hospitals, payers, providers, and patients.