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The Future of Emergency General Surgery

Havens, Joaquim M. MD*,†; Neiman, Pooja U. MD, MPA*; Campbell, Braidie L. MS; Croce, Martin A. MD§; Spain, David A. MD; Napolitano, Lena M. MD||

doi: 10.1097/SLA.0000000000003183
SURGICAL PERSPECTIVES
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*Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA

Tufts University School of Medicine, Boston, MA

§AAST President, University of Tennessee Health Science Center, Memphis, TN

AAST President-Elect, Stanford University Medical Center, Stanford, CA

||Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI.

Reprints: Joaquim M. Havens, MD, Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. E-mail: jhavens@bwh.harvard.edu.

The authors report no conflicts of interest.

Hospital admissions for Emergency General Surgery (EGS) have increased 28% since 2001, with over 27 million admissions annually, representing more hospital admissions per year than the sum of all new diagnoses of cancer or diabetes.1 Patients who undergo EGS procedures are up to 8 times more likely to die than those undergoing the same procedure electively.2 EGS admissions and costs are projected to increase 45% to $41.20 billion annually by 2060 using US Census projections.

In the early 2000s, The American Association for the Surgery of Trauma (AAST) and The American College of Surgeons defined the field of Acute Care Surgery (ACS) to address this need and establish clear practice guidelines for the promotion of safe and effective care for trauma, surgical critical care, and EGS. While trauma and surgical critical care have well-established guidelines, benchmarks, and quality improvement processes, EGS does not.

Emergency General Surgery accounts for 11% of all hospital admissions yet represents the majority (50%) of all surgical mortality in the United States. Therefore, improving healthcare outcomes in the United States will require addressing optimal care and outcomes in EGS.1,3

The issues that currently impact outcomes in EGS mirror those that Trauma Surgery faced 50 years ago. In 1976, the American College of Surgeons Committee on Trauma (ACS-COT) developed the Resources for Optimal Care of the Injured Patient Manual. This Manual defines the current trauma verification system, describes standards of care, and identifies the necessary resources for optimal care of the trauma patient. Trauma centers are required to gather quality data and study outcomes, establish quality improvement programs, engage in teaching to improve patient care, implement checklists, and have trauma-trained surgeons, and dedicated trauma care resources (operating rooms, radiology, staff, and equipment) at all times. These trauma systems-based practices have led to improved outcomes for trauma patients.4 Despite an annual incidence of 4 million patient encounters and a growth rate in hospital admissions of 28% over the past decade, such requirements have yet to be established for EGS care.1,5

We are advocating for a coordinated system of care for the EGS patient to optimize outcomes in this critical group.

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NECESSARY ARCHITECTURE FOR OPTIMAL EGS OUTCOMES

It has been confirmed that EGS patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower mortality risk. The structures and processes that improve trauma mortality have been documented to also improve EGS mortality. EGS-specific process and systems measures are needed to better understand drivers of variation in quality of EGS outcomes so that we can improve EGS outcomes. The following are elements we believe are required to achieve optimal EGS outcomes:

  • Standardized EGS definitions
  • EGS Severity assessment (clinical, anatomic, imaging) for risk-adjusted outcomes
  • National EGS data registry, which includes operative and nonoperative management
  • Standardized EGS patient care using evidence-based guidelines and bundles
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Standardized EGS Definitions

EGS patients present with a wide range of diagnoses and undergo a broad list of procedures.1,5 To accurately measure outcomes and create risk adjustment tools it is first necessary to agree upon a standardized set of EGS definitions. This would include a universal definition of EGS and the attendant complications. In addition, standardized definitions are needed for all data elements that would be used in any future EGS risk stratification tool and EGS data registry. These should be selected based on value for the purpose of research and quality improvement and must be reliably extractable from the medical record by a data registrar. It would be optimal to work toward systematic data downloads to a national EGS registry directly from electronic medical records. The development of a National EGS Data Standard is currently underway through the American Association for the Surgery of Trauma (AAST).

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Severity Assessment for Risk-adjusted Outcomes

Development of an appropriate EGS risk stratification tool would facilitate accurate outcomes measurement and benchmarking quality of care. Additionally, an EGS risk stratification tool could facilitate accurate triage of high-risk patients thereby supporting surgical decision-making, informed consent and identification of EGS patients for transfer to a higher level of care. Although low severity EGS cases performed at rural hospitals have similar morbidity and mortality to those performed at academic centers, medium and high severity EGS patients treated at rural hospitals have higher overall mortality.6

This introduces the argument for regionalization of care for EGS as is done in trauma. It has in fact been shown that hospitals with better trauma outcomes also have better EGS outcomes.3 However, the effect of regionalization of care on EGS patient outcomes, hospital resources, and surgeon workforce is not yet known.

The AAST has created an anatomic severity grading schema for 16 common EGS conditions that serves as a model for EGS severity assessment.7 An ideal EGS risk stratification tool would be able to easily and accurately predict mortality and morbidity risk early in a patient's course in both operative and nonoperative care and facilitate auditing for quality improvement. The ideal EGS risk stratification tool does not yet exist.

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National EGS Data Registry, Which Includes Operative and Nonoperative Management

A national data registry specific to EGS is needed to identify variability in patient care, specific system failures, gaps in communication and coordination, and their impact on EGS patient outcomes. Nonoperative management of disease represents a large subset of EGS care and must be included in national EGS databases for optimal quality improvement and standardization of care. A pilot EGS clinical data registry using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) infrastructure and methodology documented that although nonoperative management patients comprised only 27.4% of patients, they accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. Importantly, the addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank.8

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Standardization of Patient Care Using Evidence-based Guidelines and Bundles

Failure to establish a standardized model of EGS care likely plays a large role in the current high rates of EGS morbidity and mortality. Those institutions that have developed specialized EGS care through the formation of an acute care surgery service have lower risk-adjusted EGS mortality than institutions that do not.9

Since emergency laparotomy has a high mortality rate (14–20%), the United Kingdom established the Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle (early warning score, early antibiotics, early OR within 6 h, early resuscitation using goal-directed techniques, and ICU admission postop) to standardize care and improve outcomes. Comprehensive data were collected via the National Emergency Laparotomy Audit (NELA, http://www.nela.org.uk/) which was established to examine the inpatient care and outcomes of emergency laparotomy patients in England and Wales and to then provide comparative data to hospitals, thereby promoting local quality improvement. The ELPQuiC bundle was associated with a significant reduction in risk-adjusted mortality (15.6–9.6%, RR 0.614, 95% CI 0.451–0.836, P = 0.002) and increased the number of lives saved (6.47 to 12.44 per 100 patients, P < 0.001). In contrast, here in the United States we have not yet established standardized EGS care.10

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DISCUSSION

EGS care should be considered a national priority. It is imperative to establish a national EGS system of care that ultimately coordinates resources and improves outcomes. Despite the clear benefits and success of the trauma system in the United States, no such systems exist for the EGS population. The American Association for the Surgery of Trauma has taken up the challenge of improving outcomes for EGS patients and has begun to address the need for a national EGS system.

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CONCLUSION

Efforts to reduce the high mortality and morbidity in EGS should include standardized EGS definitions, EGS severity assessment, risk-adjusted outcomes using a national EGS registry, inclusion of operative and nonoperative care, and development of standardized EGS patient care using evidence-based guidelines and bundles.

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REFERENCES

1. Gale SC, Shafi S, Dombrovskiy VY, et al. The public health burden of emergency general surgery in the United States: a 10-year analysis of the Nationwide Inpatient Sample—2001 to 2010. J Trauma Acute Care Surg 2014; 77:202–208.
2. Havens JM, Peetz AB, Do WS, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg 2015; 78:306–311.
3. Scott JW, Tsai TC, Neiman PU, et al. Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care. J Trauma Acute Care Surg 2018; 84:433–440.
4. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006; 354:366–378.
5. Shafi S, Aboutanos MB, Agarwal S Jr, et al. Emergency general surgery: definition and estimated burden of disease. J Trauma Acute Care Surg 2013; 74:1092–1097.
6. Chaudhary MA, Shah AA, Zogg CK, et al. Differences in rural and urban outcomes: a national inspection of emergency general surgery patients. J Surg Res 2017; 218:277–284.
7. Tominaga GT, Staudenmayer KL, Shafi S, et al. The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: disease-specific criteria characterizing anatomic severity grading. J Trauma Acute Care Surg 2016; 81:593–602.
8. Wandling MW, Ko CY, Bankey PE, et al. Expanding the scope of quality measurement in surgery to include nonoperative care: results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot. J Trauma Acute Care Surg 2017; 83:837–845.
9. To KB, Kamdar NS, Patil P, et al. Michigan Surgical Quality Collaborative (MSQC) Emergency General Surgery Study Group and the MSQC Research Advisory Group. Acute care surgery model and outcomes in emergency general surgery. J Am Coll Surg 2018; Oct 22. Epub ahead of print.
10. Huddart S, Peden CJ, Swart M, et al. ELPQuiC Collaborator Group; ELPQuiC Collaborator Group. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg 2015; 102:57–66.
Keywords:

acute care surgery; emergency general surgery; surgical outcomes

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