Validation of AAST EGS Grade for Acute Pancreatitis

Timing, triage, and mode of emergency general surgery interfacility transfers in the United States: A scoping review

ABSTRACT

Interfacility transfer of emergency general surgery (EGS) patients continues to rise, especially in the context of ongoing system consolidation. This scoping review aims to identify and summarize the literature on triage, timing, and mode of interfacility emergency general surgery transfer. While common, EGS transfer systems are not optimized to improve outcomes or ensure value-based care. We identified studies investigating emergency general surgery interfacility transfer using Ovid Medline, EMBASE, and Cochrane Library between 1990 and 2022. English studies that evaluated EGS interfacility timing, triage or transfer mode were included. Studies were assessed by two independent reviewers. Studies were limited to English-language articles in the United States. Data were extracted and summarized with a narrative synthesis of the results and gaps in the literature. There were 423 articles identified, of which 66 underwent full-text review after meeting inclusion criteria. Most publications were descriptive studies or outcomes investigations of interfacility transfer. Only six articles described issues related to the logistics behind the interfacility transfer and were included. The articles were grouped into the predefined themes of transfer timing, triage, and mode of transfer. There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer. Further research should focus on better understanding which populations of patients require expedited transfer and by what mode. The lack of high-level data supports the need for robust investigations into interfacility transfer processes to optimize triage using scarce resources and optimized value-based care.

Value in acute care surgery, part 2: Defining and measuring quality outcomes

ABSTRACT

The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.

Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues

Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.

Evaluating the association between American Association for the Surgery of Trauma emergency general surgery anatomic severity grades and clinical outcomes using national claims data

BACKGROUND

Emergency general surgery (EGS) encompasses a heterogeneous population of acutely ill patients, and standardized methods for determining disease severity are essential for comparative effectiveness research and quality improvement initiatives. The American Association for the Surgery of Trauma (AAST) has developed a grading system for the anatomic severity of 16 EGS conditions; however, little is known regarding how well these AAST EGS grades can be approximated by diagnosis codes in administrative databases.

METHODS

We identified adults admitted for 16 common EGS conditions in the 2012 to 2017q3 National Inpatient Sample. Disease severity strata were assigned using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes based on AAST EGS anatomic severity grades. We evaluated whether assigned EGS severity (multiple strata or dichotomized into less versus more complex) were associated with in-hospital mortality, complications, length of stay, discharge disposition, and costs. Analyses were adjusted for age, sex, comorbidities, hospital traits, geography, and year.

RESULTS

We identified 10,886,822 EGS admissions. The number of anatomic severity strata derived from ICD-9/10-CM codes varied by EGS condition and by year. Four conditions mapped to four strata across all years. Two conditions mapped to four strata with ICD-9-CM codes but only two or three strata with ICD-10-CM codes. Others mapped to three or fewer strata. When dichotomized into less versus more complex disease, patients with more complex disease had worse outcomes across all 16 conditions. The addition of multiple strata beyond a binary measure of complex disease, however, showed inconsistent results.

CONCLUSION

Classification of common EGS conditions according to anatomic severity is feasible with International Classification of Diseases codes. No condition mapped to five distinct severity grades, and the relationship between increasing grade and outcomes was not consistent across conditions. However, a standardized measure of severity, even if just dichotomized into less versus more complex, can inform ongoing efforts aimed at optimizing outcomes for EGS patients across the nation.

LEVEL OF EVIDENCE

Prognostic, level III.

Comparison of American Association for the Surgery of Trauma grading scale with modified Hinchey classification in acute colonic diverticulitis: A pilot study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes.

METHODS

This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality.

RESULTS

One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80.

CONCLUSION

The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions

Objective

Emergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care.

Methods

The grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption.

Results

We identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow.

Conclusions

The uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it.

Level of evidence

Level III.

Validation of the American Association for the Surgery of Trauma grading system for acute mesenteric ischemia-More than anatomic severity is needed to determine risk of mortality

BACKGROUND

Acute mesenteric ischemia (AMI) is a highly morbid disease with a diverse etiology. The American Association for the Surgery of Trauma (AAST) proposed disease-specific grading scales intended to quantify severity based upon clinical, imaging, operative, and pathology findings. This grading scale has not been yet been validated for AMI. The goal of this study was to evaluate the correlation between the grading scale and complication severity.

METHODS

Patients for this single center retrospective chart review were identified using diagnosis codes for AMI (ICD10-K55.0, ICD9-557.0). Inpatients >17 years old from the years 2008 to 2015 were included. The AAST grades (1-5) were assigned after review of clinical, imaging (computed tomography), operative and pathology findings. Two raters applied the scales independently after dialog with consensus on a learning set of cases. Mortality and Clavien-Dindo complication severity were recorded.

RESULTS

A total of 221 patients were analyzed. Overall grade was only weakly correlated with Clavien-Dindo complication severity (rho = 0.27) and mortality (rho = 0.21). Computed tomography, pathology, and clinical grades did not correlate with mortality or outcome severity. There was poor interrater agreement between overall grade. A mortality prediction model of operative grade, use of vasopressors, preoperative serum creatinine and lactate levels showed excellent discrimination (c-index = 0.93).

CONCLUSION

In contrast to early application of other AAST disease severity scales, the AMI grading scale as published is not well correlated with outcome severity. The AAST operative grade, in conjunction with vasopressor use, creatinine, and lactate were strong predictors of mortality.

LEVEL OF EVIDENCE

Prognostic study, III.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice

Background

Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level.

Aim

To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes.

Methods

A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission.

Endpoints

A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay.

Results

Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low.

Conclusion

This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich ‘real world’ insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study

INTRODUCTION

Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs).

METHODS

This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability.

RESULTS

1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well.

CONCLUSION

This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic retrospective multicenter trial, level III.

American Association for the Surgery of Trauma emergency general surgery guidelines gap analysis

BACKGROUND

Emergency general surgery (EGS) has been rapidly adopted as one of the major components of acute care surgery. Although heterogenous, the most common disease states that comprise EGS often have published guidelines containing recommendations for their diagnosis and management. Not all diseases included within EGS however have published guidelines and existing guidelines may have important gaps in their recommendations. We present a thorough assessment of the existing guidelines for the most common EGS diseases and highlight gaps that will require additional literature review or new research to fill.

METHODS

Literature searches for existing comprehensive guidelines were performed. These guidelines were summarized based on level of supporting evidence and further subcategorized based on American Association for the Surgery of Trauma (AAST) grade of disease. Using these summaries, gaps in the exiting recommendations were then generated and refined through review by at least two authors.

RESULTS

The initial gap analysis focused on diverticulitis, acute pancreatitis, small bowel obstruction and acute cholecystitis. Despite extensive research into each of these disease processes, critical questions regarding diagnosis and management remain to be answered. Gaps were the result of either low quality research or a complete lack of research. The use of the AAST grade of disease established a framework for evaluating these guidelines and grouping the recommendations.

CONCLUSIONS

Despite extensive prior research, EGS diseases have multiple areas where additional research would likely result in improved patient care. Consensus on the most important areas for additional research can be obtained through analysis of gaps in existing guidelines. This gap analysis has the potential to inform efforts around developing a research agenda for EGS.