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Improving Outcomes in Emergency General Surgery Patients: What Evidence Is Out There?

Aggarwal, Geeta MRCP, FRCA*; Peden, Carol J. FRCA, MD, MPH; Quiney, Nial F. FRCA*

doi: 10.1213/ANE.0000000000002190
The Open Mind: The Open Mind

Published ahead of print June 16, 2017.

From the *Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, United Kingdom; and Department of Anesthesiology and USC Center for Health System Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California.

Accepted for publication March 30, 2017.

Published ahead of print June 16, 2017.

Funding: N.F. Quiney and C.J. Peden were funded by The Health Foundation UK (London, UK) for the ELPQuIC study. All the authors received funding for the ongoing Emergency Laparotomy Collaborative from the Health Foundation, United Kingdom.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Geeta Aggarwal, MRCP, FRCA, Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Rd, Guildford GU2 7XX, United Kingdom. Address e-mail to 1geeta@gmail.com.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Emergency general surgery (EGS) was defined by the American Association for the Surgery of Trauma in 2013 as “any patient (inpatient or emergency department) requiring an emergency surgical evaluation for diseases within the realm of general surgery as defined by the American Board of Surgery.” This classification encompasses a large number of different conditions ranging from abdominal wall hernias to ischemic bowel and excludes presentations due to trauma. Over 2 million EGS patients will present in the United States each year.1 In a large retrospective study, Gale et al2 examined the burden of EGS over a 10-year period in the United States. They found EGS activity accounted for over 7% of all hospital admissions (with the annual case rate being higher than the sum of all new cancer diagnoses) and increased by over 27% between 2001 and 2010. Again in the United States, Smith et al3 reviewed the burden of mortality and costs of EGS patients with a measureable risk of mortality identified by the Veterans Affairs Surgical Quality Improvement Program. They found that these EGS patients accounted for 11% of total surgical cases, but constituted 47% of all surgical deaths and 28% of complications. In a UK study of high-risk EGS admissions, with a predicted mortality of >5%,4 in-hospital mortality at 30 days was very high for all types of intra-abdominal presentation ranging from 47.4% for bowel ischemia to 27% for peritonitis, with the lowest rate for liver and biliary conditions at 7.4%. These patients are likely to have had significant underlying physiological and pathological insults contributing to the high mortality with a large number having sepsis and fluid shifts.4,5

While this group of patients is well-known clinically to anesthesiologists, there has only relatively recently been a focus on potential ways to improve care for these high-risk patients.

A subset of patients presenting with an emergency general surgical diagnosis require an emergency laparotomy.4 This term encompasses a large number of procedures requiring surgical exploration of the abdomen for therapeutic or diagnostic reasons.4 Al-Temimi et al6 in 2012 reported on emergency laparotomy outcomes using a large patient sample collected over 4 years from the National Surgical Quality Improvement Program (NSQIP) database. Intestinal obstruction and perforation were the most common conditions requiring laparotomy (33% and 19%, respectively), and the overall 30-day mortality rate was 14.9%. Mortality in the very elderly patients who had other preexisting comorbidities was even higher; more than 90% of patients with functional dependence and sepsis over the age of 90 years died. Similar high mortality rates have been reported in Europe. The Emergency Laparotomy Network7 in the United Kingdom reported an almost identical mortality rate to that of the Al-Temimi study of 14.4% at 30 days, rising to 25% in patients over 80 years of age. The Danish national registry reported an even higher average overall 30-day mortality of 18.5% in patients undergoing emergency laparotomy.8 The high mortality rates reported in the Network study7 led to the establishment of the National Emergency Laparotomy Audit in the UK, and data have been collected describing the care and outcomes of all patients undergoing emergency laparotomy surgery in England and Wales since December 2013.9 Two annual reports have been published to date. The audit records performance against defined standards and can identify variations in care potentially amenable to improvement.

The outcomes of patients with advanced cancer who underwent emergency intra-abdominal surgery were reviewed by Cauley et al.10 In patients who had suffered a perforation, there was a 30-day mortality of 34%. Sixty-seven percent developed complications and 52% were discharged to an institution. The appropriateness of surgery was questioned for many of these patients with such high intensity treatment found to prolong suffering without meeting the patient’s goals at the end of life.

The evidence is clear. Mortality for EGS patients is high, and for some groups of patients such as the elderly undergoing laparotomy, and those with advanced malignancy, it is very high. Variations in outcome between hospitals have been demonstrated, suggesting improvements in care can be achieved.3,7,9 The use of a standardized patient-centered multidisciplinary pathway of care in elective surgery has been promoted by both the Perioperative Surgical Home (PSH) in the United States and the Enhanced Recovery After Surgery (ERAS) program in Europe. A significant evidence base is now available showing that the use of a standardized or ERAS pathway is beneficial, both in terms of patient outcomes and reduced costs.11 Despite successes for elective surgical patients, surprisingly little attention has been paid worldwide to adopting the same principles of standardized, evidence-based care pathways for EGS patients. While not all components of the perioperative surgical home or enhanced recovery protocols can be applied to patients undergoing emergency surgery, many of the central elements such as protocolized intraoperative and postoperative pathways and coordinated transitions of care can be utilized.

In the United Kingdom, a 4-center quality improvement project (ELPQuIC), based on concepts modeled by enhanced recovery and the perioperative surgical home, demonstrated that implementation of a simple, evidence-based, care bundle approach over an 8-month period in the participating hospitals reduced crude mortality at 30 days by 25% and risk-adjusted (using the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity12) in-hospital mortality by 42%.13 Møller et al14 from Denmark implemented a more complex and comprehensive evidence-based care pathway for patients undergoing emergency surgery for perforated peptic ulcer across a group of hospitals. They also demonstrated a one-third reduction in 30-day mortality. Tengberg et al15 reported comparable reductions in mortality in a single institution in Denmark using a similar approach.

The 3 studies above aimed to reliably deliver essential elements of care to every patient presenting for major EGS. Although the approach of each study was not exactly the same, there were several key elements that all 3 publications recommended:

  1. The early identification and resuscitation of EGS patients. An early warning scoring system and/or arterial lactate concentration were used as triggers to prompt intervention throughout these studies.
  2. The early identification and treatment of patients with sepsis according to the “Surviving Sepsis” guidelines. A recent study showed that 1 in 5 patients presenting for EGS fulfill sepsis criteria5 rising to 1 in 4 for those patients requiring emergency laparotomy.6 The quick sepsis-related organ failure assessment score may help identify those septic patients at risk of deterioration more quickly. This uses 3 clinical elements: hypotension, altered mentation, and tachypnea.
  3. Prioritization of EGS patients to early surgical intervention which has been shown to significantly reduce mortality.16
  4. The use of a protocolized fluid management strategy has been common to all 3 studies. This has incorporated the use of a noninvasive cardiac output monitoring device to measure dynamic fluid responsiveness in addition to standard hemodynamic measurements. Dehydration and fluid shifts are commonly seen in EGS patients.5 Protocol-driven fluid resuscitation and maintenance of intravascular volume have been shown to be associated with fewer postoperative complications and reduced length of stay.17
  5. Admission after surgery of all patients to either intensive care or a similar high-intensity postoperative care area. Hospitals that have ready access to postoperative critical care facilities have been shown to be associated with a low mortality after EGS.4
  6. The early and continued involvement of senior surgical, anesthesiology, and intensive care professionals to best provide complex care to this high-risk patient group. This was again a feature in all 3 studies that showed such dramatic reductions in in-hospital mortality.

This standardization of practice using evidence-based goals and the delivery of each component can be facilitated using quality improvement methodology. The approach used by the Institute for Health Improvement based on the “The Model for Improvement” with “Plan-Do-Study-Act” cycles drives rapid iterative improvements. Coupled with time-sensitive data analysis such as run charts and statistical process control (SPC) charts, these can identify performance and changes following interventions in health care. This methodology was used in the ELPQuIC study.13 Such an approach has been shown to be successful in many diverse improvement projects. Integration of quality metrics and an improvement methodology, in line with the PSH approach, should be considered by teams implementing pathways to improve care for EGS patients.

What else can we do to improve outcomes for patients undergoing emergency surgery? First, the regular widespread recording and reporting of EGS outcomes using clear definitions for the patient population1,4,7,9 is imperative. Individual institutions should review their own performance data and define areas for improvement. Standardization of key aspects of care, such as time from decision to operate to time of surgery, should be agreed and improvement work undertaken to ensure reliable delivery. Second, some hospitals are now reporting risk-adjusted 30-day mortality rates of 5%–6% for emergency laparotomy compared with the earlier reports of over 14%. The National Emergency Laparotomy Audit database in the United Kingdom has shown an apparent reduction in mortality for emergency laparotomy across England and Wales to 11.1%.9 The performance of hospitals with a low and improved mortality (the positive deviants) needs to be highlighted more widely, and the processes of care that are able to achieve these results needs to be carefully examined and described. In addition, follow-up of patients after discharge with measurement of quality of life and overall cost-effectiveness of the use of a standardized care pathway should be further studied.

Third, the care of elderly patients needs to be better understood. Elderly patients are more likely to present for EGS than younger patients due to the increasing incidence of intestinal malignancy associated with aging.7 In addition, many patients over the age of 75 years present with multiple comorbidities for EGS. Over 70% of patients over the age of 75 years develop postoperative complications and many of these patients face, at best, prolonged stays on intensive care with little chance of returning to independent living.18 Delirium and cognitive decline are common postoperative complications and may occur in up to 50% of EGS patients with a high predictive value for prolonged length of stay and institutional discharge.19 Guidelines recommending methods of screening, identification, and treatment of delirium are available and should be in widespread use.20 If elderly patients are able to leave hospital, little is known of their ongoing life expectancy, likely return to premorbid functional status or quality of life. Further studies in this area are needed to help inform patients of likely outcomes before surgery is undertaken.

Finally, the development and widespread adoption of a standardized risk-scoring tool, incorporating frailty assessment and validating for EGS patients, would be extremely useful. Patients who present for EGS are often elderly, frail, dependent, or have advanced disease processes. An assessment of the suitability for high-intensity surgical treatment needs to be made for each patient. Many of these patients, when asked, do not want to experience prolonged stays in intensive care, suffer complications and discomfort, or end up with a high degree of ongoing nursing and physical support.21 The use of an accurate risk-scoring system will enable a more rational discussion about the suitability of surgical intervention to be made with elderly EGS patients. The ability to predict outcomes (both morbidity and mortality) at a population level, to better inform discussions with the patient and their family would help make these discussions easier. Specific training in difficult communication, with a standardized approach, has been shown to be helpful to both patient and caregiver.

Evidence is accumulating that protocol-driven care and consistent application of evidence-based standards of care in the perioperative period can substantially improve outcomes for high-risk EGS patients.13–15 Further studies of particularly vulnerable groups, such as the elderly patients and patients with advanced malignancy, are required. Long-term outcomes and quality of life must be better understood to inform patients and families about the risks of surgery and to provide those patients undergoing EGS with the best understanding of both their chances of survival and likely expected quality of life after hospital discharge.

Those institutions or groups that have led the way in implementation of pathways of care for elective patients in line with the PSH and ERAS concepts should apply the same principles to the care of EGS patients. Anesthesiologists should play a major role in developing key standards of care for EGS patients and study how to deliver those standards consistently. Perioperative pathways for EGS may need to be modified to address local circumstances but the application of the central components of PSH and ERAS together with specific quality improvement tools such as “The Model for Improvement” is highly transferable anywhere in the world.

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DISCLOSURES

Name: Geeta Aggarwal, MRCP, FRCA.

Contribution: This author helped conceive the article, as well as draft and revise it.

Name: Carol J. Peden, FRCA, MD, MPH.

Contribution: This author helped draft and revise the article.

Name: Nial F. Quiney, FRCA.

Contribution: This author helped conceive, design, and revise the article.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

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