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.

Post-hospitalization Treatment Regimen and Readmission for C. difficile Colitis in Medicare Beneficiaries.

BACKGROUND: C. difficile (CDI) has surpassed methicillin-resistant staph aureus as the most common nosocomial infection with recurrence reaching 30% and the elderly being disproportionately affected. We hypothesized that post-discharge antibiotic therapy for continued CDI treatment reduces readmissions. STUDY DESIGN: We queried a 5% random sample of Medicare claims (2009-2011 Part A and Part D; n = 864,604) for hospitalizations with primary or secondary diagnosis of CDI. We compared demographics, comorbidities, and post-discharge CDI treatment (no CDI treatment, oral metronidazole only, oral vancomycin only, or both) between patients readmitted with a primary diagnosis of CDI within 90 days and patients not readmitted for any reason using univariate tests of association and multivariable models. RESULTS: Of 7042 patients discharged alive, 945 were readmitted ≤90 days with CDI (13%), while 1953 were not readmitted for any reason (28%). Patients discharged on dual therapy had the highest rates of readmission (50%), followed by no post-discharge CDI treatment (43%), vancomycin only (28%), and metronidazole only (19%). Patients discharged on only metronidazole (OR 0.28) or only vancomycin (OR 0.42) had reduced odds of 90-day readmission compared to patients discharged on no CDI treatment. Patients discharged on dual therapy did not vary in odds of readmission. CONCLUSIONS: Thirteen percent of patients discharged with CDI are readmitted within 90 days. Patients discharged with single-drug therapy for CDI had lower readmission rates compared to patients discharged on no ongoing CDI treatment suggesting that short-term monotherapy may be beneficial in inducing eradication and preventing relapse. Half of patients requiring dual therapy required readmission, suggesting patients with symptoms severe enough to warrant discharge on dual therapy may benefit from longer hospitalization.

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.

Upper Gastrointestinal Perforations: A Possible Danger of Antibiotic Overuse.

BACKGROUND: The role of changes in gut microflora on upper gastrointestinal (UGI) perforations is not known. We conducted a retrospective case-control study to examine the relationship between antibiotic exposure-a proxy for microbiome modulation-and UGI perforations in a national sample. METHODS: We queried a 5% random sample of Medicare (2009-2013) to identify patients ≥ 65 years old hospitalized with UGI (stomach or small intestine) perforations using International Classification of Diseases diagnosis codes. Cases with UGI perforations were matched with 4 controls, each based on age and sex. Exposure to outpatient antibiotics (0-30, 31-60, 61-90 days) prior to case patients' index hospitalization admission data was determined with Part D claims. Univariate and multivariable regression analyses were performed to evaluate the effect of antibiotic exposure on UGI perforation. RESULTS: Overall, 504 cases and 2016 matched controls were identified. Compared to controls, more cases had antibiotic exposure 0-30 days (19% vs. 3%, p < 0.001) and 31-60 days (5% vs. 2%, p < 0.001) prior to admission. In adjusted analyses, antibiotic exposure 0-30 days prior to admission was associated with 6.8 increased odds of an UGI perforation (95% CI 4.8, 9.8); 31-60 days was associated with 1.9 increased odds (95% CI 1.1, 3.3); and 61-90 days was associated with 3.7 increased odds (95% CI 2.0, 6.9). CONCLUSIONS: Recent outpatient antibiotic use, in particular in the preceding 30 days, is associated with UGI perforation among Medicare beneficiaries. Exposure to antibiotics, one of the most modifiable determinants of the microbiome, should be minimized in the outpatient setting.

Association between operating room access and mortality for life-threatening general surgery emergencies.

BACKGROUND: Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals. METHODS: In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables. RESULTS: Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1). CONCLUSION: Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence. LEVEL OF EVIDENCE: Therapeutic, level III.

Outpatient beta-blockers and survival from sepsis: Results from a national cohort of Medicare beneficiaries.

BACKGROUND: Elderly Americans suffer increased mortality from sepsis. Given that beta-blockers have been shown to be cardioprotective in critical care, we investigated outpatient beta-blocker prescriptions and mortality among Medicare beneficiaries admitted for sepsis. METHODS: We queried a 5% random sample of Medicare beneficiaries for patients admitted with sepsis. We used in-hospital and outpatient prescription drug claims to compare in-hospital and 30-day mortality based on pre-admission beta-blocker prescription and class of beta-blocker prescribed using univariate tests of comparison and multivariable logistic regression models and another class of medications for control. RESULTS: Outpatient beta-blocker prescription was associated with a statistically significant decrease in in-hospital and 30-day mortality. In multivariable modeling, beta-blocker prescription was associated with 31% decrease in in-hospital mortality and 41% decrease in 30-day mortality. Both cardioselective and non-selective beta-blockers conferred mortality benefit. CONCLUSIONS: Our data suggests that there may be a role for preadmission beta-blockers in reducing sepsis-related mortality.

The impact of acute care surgery on appendicitis outcomes: Results from a national sample of university-affiliated hospitals.

BACKGROUND: Acute appendicitis is the most common indication for emergency general surgery (EGS) in the United States. We examined the role of acute care surgery (ACS) on interventions and outcomes for acute appendicitis at a national sample of university-affiliated hospitals. METHODS: We surveyed senior surgeons responsible for EGS coverage at University HealthSystems Consortium hospitals, representing more than 90% of university-affiliated hospitals in the United States. The survey elicited data on resources allocated for EGS during 2013. Responses were linked to University HealthSystems Consortium outcomes data by unique hospital identifiers. Patients treated at hospitals reporting hybrid models for EGS coverage were excluded. Differences in interventions and outcomes between patients with acute appendicitis treated at ACS hospitals versus hospitals with a general surgeon on-call model (GSOC) were analyzed using univariate comparisons and multivariable logistic regression models adjusted for patient demographics, clinical acuity, and hospital characteristics. RESULTS: We found 122 hospitals meeting criteria for analysis where 2,565 patients were treated for acute appendicitis. Forty-eight percent of hospitals had an ACS model (n = 1,414), and 52% had a GSOC model (n = 1,151). Hospitals with ACS models were more likely to treat minority patients than those with GSOC models. Patients treated at ACS hospitals were more likely to undergo laparoscopic appendectomy. In multivariable modeling of patients who had surgery (n = 2,258), patients treated at ACS hospitals had 1.86 (95% confidence interval, 1.23-2.80) greater odds of undergoing laparoscopic appendectomy. CONCLUSION: In an era when laparoscopic appendectomy is increasingly accepted for treating uncomplicated acute appendicitis, particularly in low-risk patients, it is concerning that patients treated at GSOC model hospitals are more likely to undergo traditional open surgery at the time of presentation. Furthermore, hospitals with ACS are functioning as safety-net hospitals for vulnerable patients with acute appendicitis. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Predictors and outcomes of readmission for Clostridium difficile in a national sample of medicare beneficiaries.

BACKGROUND: Rates of Clostridium difficile (CD) infections are increasing. Elderly patients may be at particular risk of recurrent CD infection. Little is known about the risk for CD readmission specifically in this age group. METHODS: A 5% random sample of Medicare data (2009-2011) was queried for patients surviving a hospitalization for CD by ICD-9 code. Demographic (age, sex, gender), clinical (Elixhauser index, gastrointestinal comorbidities), and hospitalization (length of stay, ICU admission) characteristics as well as exposure to antibiotics and interim non-CD hospitalization were compared for those with and without a readmission for CD. A multivariable survival analysis was used to determine predictors of readmission. RESULTS: Of 7,564 patients surviving a CD hospitalization, 8.5% were readmitted with CD in a median of 25 days (interquartile range (IQR) 14-57). In multivariable survival analyses, interim non-CD hospital exposure was the strongest predictor of CD readmission (hazard ration (HR) 3.75 95%, confidence interval (CI) 3.2-4.42). Oral and intravenous/intramuscular (IV/IM) antibiotic use, Elixhauser index, and CD as the primary diagnosis also increased the risk of CD readmission. Discharge to hospice, long-term care or a skilled nursing facility decreased the odds of CD readmission. CONCLUSION: Hospital exposure and antibiotic use put elderly patients at risk of CD readmission. Exposure to these factors should be minimized in the immediate post discharge period.

Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals.

BACKGROUND: To date, no studies have reported nationwide adoption of acute care surgery (ACS) or identified structural and/or process variations for the care of emergency general surgery (EGS) patients within such models. METHODS: We surveyed surgeons responsible for EGS coverage at University Health Systems Consortium hospitals using an eight-page postal/e-mail questionnaire querying respondents on hospital and EGS structure/process measures. Survey responses were analyzed using descriptive statistics, univariate comparisons, and multivariable regression models. RESULTS: Of 319 potential respondents, 258 (81%) completed the surveys. A total of 81 hospitals (31%) had implemented ACS, while 134 (52%) had a traditional general surgeon on-call (GSOC) model. Thirty-eight hospitals (15%) had another model (hybrid). Larger-bed, university-based, teaching hospitals with Level 1 trauma center verification status located in urban areas were more likely to have adopted ACS. In multivariable modeling, hospital type, setting, and trauma center verification predicted ACS implementation. EGS processes of care varied, with 28% of the GSOC hospitals having block time versus 67% of the ACS hospitals (p < 0.0001), 45% of the GSOC hospitals providing ICU [intensive care unit] care to EGS patients in a surgical/trauma ICU versus 93% of the ACS hospitals (p < 0.0001), 5.7 ± 3.2 surgeons sharing call at GSOC hospitals versus 7.9 ± 2.3 surgeons at ACS hospitals (p < 0.0001), and 13% of the GSOC hospitals requiring in-house EGS call versus 75% of the ACS hospitals (p < 0.0001). Among ACS hospitals, there were variations in patient cohorting (EGS patients alone, 25%; EGS + trauma, 21%; EGS + elective, 17%; and EGS + trauma + elective, 30%), data collection (26% had prospective EGS registries), patient hand-offs (56% had attending surgeon presence), and call responsibilities (averaging 4.8 ± 1.3 calls per month, with 60% providing extra call stipend and 40% with no postcall clinical duties). CONCLUSION: The potential of the ACS on the national crisis in access to EGS care is not fully met. Variations in EGS processes of care among adopters of ACS suggest that standardized criteria for ACS implementation, much like trauma center verification criteria, may be beneficial.

Epidemiology and outcomes of community-acquired Clostridium difficile infections in Medicare beneficiaries.

BACKGROUND: The incidence of community-acquired Clostridium difficile (CACD) is increasing in the United States. Many CACD infections occur in the elderly, who are predisposed to poor outcomes. We aimed to describe the epidemiology and outcomes of CACD in a nationally representative sample of Medicare beneficiaries. STUDY DESIGN: We queried a 5% random sample of Medicare beneficiaries (2009-2011 Part A inpatient and Part D prescription drug claims; n = 864,604) for any hospital admission with a primary ICD-9 diagnosis code for C difficile (008.45). We examined patient sociodemographic and clinical characteristics, preadmission exposure to oral antibiotics, earlier treatment with oral vancomycin or metronidazole, inpatient outcomes (eg, colectomy, ICU stay, length of stay, mortality), and subsequent admissions for C difficile. RESULTS: A total of 1,566 (0.18%) patients were admitted with CACD. Of these, 889 (56.8%) received oral antibiotics within 90 days of admission. Few were being treated with oral metronidazole (n = 123 [7.8%]) or vancomycin (n = 13 [0.8%]) at the time of admission. Although 223 (14%) patients required ICU admission, few (n = 15 [1%]) underwent colectomy. Hospital mortality was 9%. Median length of stay among survivors was 5 days (interquartile range 3 to 8 days). One fifth of survivors were readmitted with C difficile, with a median follow-up time of 393 days (interquartile range 129 to 769 days). CONCLUSIONS: Nearly half of the Medicare beneficiaries admitted with CACD have no recent antibiotic exposure. High mortality and readmission rates suggest that the burden of C difficile on patients and the health care system will increase as the US population ages. Additional efforts at primary prevention and eradication might be warranted.