40: PERIOPERATIVE CRITICAL CARE PRACTICES AND MORTALITY AMONG PATIENTS WITH GENERAL SURGERY EMERGENCIES

Abstract

Learning Objectives: Patients with life-threatening emergency general surgery disease (e.g., perforated viscus, necrotizing fasciitis, gangrenous bowel LTEGS) require peri-operative critical care (CC). We measured nationwide CC delivery practices and evaluated if round-the-clock (RTC) CC, surgeons providing CC, protocolizing adherence to national guidelines, among other CC practices improved mortality among LTEGS patients. Methods: We surveyed 2,811 hospitals on EGS practices with a specific focus on CC resources and infrastructure. 1,690 (60%) hospitals responded. We linked survey data to 2015 Statewide Inpatient Sample data from 16 states using American Hospital Association identifiers to survey data anonymously. We assessed mortality amongst patients admitted for LTEGS. Univariate and multivariate regression analyses were performed with clustering of treating hospitals and adjustment for patient factors in order to assess the impact of CC services on overall in-patient mortality. Results: 5,197 patients were admitted with LTEGS. The majority were white (80%) with a median age of 62 years (IQR 50,75), ≥ 3 comorbidities (41.4%), and on Medicare (50.1%). Overall mortality was 6.6% (N = 343 patients). 49% of hospitals provided RTC CC (N = 749 hospitals). In bivariate comparisons, hospitals with RTC CC were more likely to have in-house providers who could intubate patients (98% vs. 89%, p < 0.0001), protocols to identify patients who needed post-operative ICU care (27% vs. 19%, p < 0.0001), and protocols adhering to the Surviving Sepsis Guidelines (92% vs. 67%, p < 0.0001). In multivariable analyses, noncompliance with Surviving Sepsis Guidelines was the only practice variation associated with an increased odds of mortality (OR 1.66 [95% CI 1.11–2.47]). Conclusions: There are substantial practice variations in the delivery of CC to patients with LTEGS conditions. However, no practices other than ensuring compliance to Surviving Sepsis Guidelines conferred survival advantage. Our findings have implications for implementation of evidence-based CC practices nationally and for the standardization of peri-operative CC practices in an effort to reduce in-hospital mortality. CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MDCCM