M. Didem Ayturk

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.

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.

Disparities in access to emergency general surgery care in the United States

Background As fewer surgeons take emergency general surgery call and hospitals decrease emergency services, a crisis in access looms in the United States. We examined national emergency general surgery capacity and county‐level determinants of access to emergency general surgery care with special attention to disparities. Methods To identify potential emergency general surgery hospitals, we queried the database of the American Hospital Association for “acute care general hospital,” with “surgical services,” and “emergency department,” and ≥1 “operating room.” Internet search and direct contact confirmed emergency general surgery services that covered the emergency room 7 days a week, 24 hours a day. Geographic and population‐level emergency general surgery access was derived from Geographic Information Systems and US Census. Results Of the 6,356 hospitals in the 2013 American Hospital Association database, only 2,811 were emergency general surgery hospitals. Counties with greater percentages of black, Hispanic, uninsured, and low‐education individuals and rural counties disproportionately lacked access to emergency general surgery care. For example, counties above the 75th percentile of African American population (10.2%) had >80% odds of not having an emergency general surgery hospital compared with counties below the 25th percentile of African American population (0.6%). Conclusion Gaps in access to emergency general surgery services exist across the United States, disproportionately affecting underserved, rural communities. Policy initiatives need to increase emergency general surgery capacity nationwide.

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.

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.