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Sakowitz S, Bakhtiyar SS, Gao Z, Mallick S, Vadlakonda A, Coaston T, Balian J, Chervu N, Benharash P. Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis. Am Surg 2024; 90:2374-2383. [PMID: 38570318 DOI: 10.1177/00031348241244642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
BACKGROUND Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort. METHODS All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest. RESULTS Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (β + 1.04 days, CI + .91-1.17) and greater costs (β+$3,490, CI + 2840-4140). DISCUSSION While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.
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Affiliation(s)
- Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Denver, Aurora, CO, USA
| | - Zihan Gao
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Troy Coaston
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeffrey Balian
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
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Nzenwa IC, Abiad M, Lagazzi E, Rafaqat W, Panossian VS, Argandykov D, Arnold SC, Hoekman AH, Paranjape CN, DeWane MP, Velmahos GC, Hwabejire JO. Lost in transition: Impact of interhospital transfer on outcomes after emergency general surgery in the older adult population. Surgery 2024:S0039-6060(24)00313-1. [PMID: 38876901 DOI: 10.1016/j.surg.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/22/2024] [Accepted: 05/07/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Emergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients. METHODS Emergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort. RESULTS Among the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients. CONCLUSION Interhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes.
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Affiliation(s)
- Ikemsinachi C Nzenwa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/ICNzenwa
| | - May Abiad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States; Maternal Fetal Care Center, Division of Fetal and Newborn Medicine, Boston Children's Hospital, Boston, MA, United States. https://twitter.com/AbiadMay
| | - Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/EmanueleLagazzi
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/RafaqatWardah
| | - Vahe S Panossian
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/VahePanossian
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/argandykov
| | - Suzanne C Arnold
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Anne H Hoekman
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/annehhoekman
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/CharuParanjape
| | - Michael P DeWane
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States. https://twitter.com/michaeldewane
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States.
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Bass GA, Kaplan LJ, Gaarder C, Coimbra R, Klingensmith NJ, Kurihara H, Zago M, Cioffi SPB, Mohseni S, Sugrue M, Tolonen M, Valcarcel CR, Tilsed J, Hildebrand F, Marzi I. European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities. Eur J Trauma Emerg Surg 2024; 50:367-382. [PMID: 38411700 PMCID: PMC11035411 DOI: 10.1007/s00068-023-02441-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/28/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature. METHODS Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society. RESULTS Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training. CONCLUSIONS This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA.
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA, USA.
| | - Lewis Jay Kaplan
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
- Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
| | - Christine Gaarder
- Department of Traumatology at Oslo University Hospital Ullevål (OUH U), Olso, Norway
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Nathan John Klingensmith
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
| | - Hayato Kurihara
- State University of Milan, Milan, Italy
- Emergency Surgery Unit, Ospedale Policlinico di Milano, Milan, Italy
| | - Mauro Zago
- General & Emergency Surgery Division, A. Manzoni Hospital, ASST, Lecco, Lombardy, Italy
| | | | - Shahin Mohseni
- Department of Surgery, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
- Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Michael Sugrue
- Letterkenny Hospital and Galway University, Letterkenny, Ireland
| | - Matti Tolonen
- Emergency Surgery, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, HUS, Finland
| | | | - Jonathan Tilsed
- Hull Royal Infirmary, Anlaby Road, Hu3 2Jz, Hull, England, UK
| | - Frank Hildebrand
- Department of Orthopaedics Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany.
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Schneider R, Perugini R, Karthikeyan S, Okereke O, Herscovici DM, Richard A, Doan T, Suh L, Carroll JE. Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay. Surg Endosc 2024; 38:1576-1582. [PMID: 38182799 DOI: 10.1007/s00464-023-10600-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy). METHODS Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital. RESULTS A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided t-test (p = 0.05). CONCLUSION Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.
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Affiliation(s)
- R Schneider
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA.
| | - Richard Perugini
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - S Karthikeyan
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - O Okereke
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - D M Herscovici
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - A Richard
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - T Doan
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - L Suh
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
| | - James E Carroll
- Department of Surgery, University of Massachusetts Chan School of Medicine, Rachel Schneider, 514 Plantation Street, Worcester, MA, 01605, USA
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Abella M, Hayashi J, Martinez B, Inouye M, Rosander A, Kornblith L, Elkbuli A. A National Analysis of Racial and Sex Disparities Among Interhospital Transfers for Emergency General Surgery Patients and Associated Outcomes. J Surg Res 2024; 294:228-239. [PMID: 37922643 DOI: 10.1016/j.jss.2023.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/20/2023] [Accepted: 09/04/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Studies focusing on Emergency General Surgery (EGS) and Interhospital Transfer (IHT) and the association of race and sex and morbidity and mortality are yet to be conducted. We aim to investigate the association of race and sex and outcomes among IHT patients who underwent emergency general surgery. METHODS A retrospective review of adult patients who were transferred prior to EGS procedures using the National Surgery Quality Improvement Project from 2014 to 2020. Multivariable logistic regression models were used to compare outcomes (readmission, major and minor postoperative complications, and reoperation) between interhospital transfer and direct admit patients and to investigate the association of race and sex for adverse outcomes for all EGS procedures. A secondary analysis was performed for each individual EGS procedure. RESULTS Compared to patients transferred directly from home, IHT patients (n = 28,517) had higher odds of readmission [odds ratio (OR): 1.004, 95% confidence interval (CI) (1.002-1.006), P < 0.001], major complication [adjusted OR: 1.119, 95% CI (1.117-1.121), P < 0.001), minor complication [OR: 1.078, 95% CI (1.075-1.080), P < 0.001], and reoperation [OR: 1.014, 95% CI (1.013-1.015), P < 0.001]. In all EGS procedures, Black patients had greater odds of minor complication [OR 1.041, 95% CI (1.023-1.060), P < 0.001], Native Hawaiian and Pacific Islander patients had greater odds of readmission [OR 1.081, 95% CI (1.008-1.160), P = 0.030], while Asian and Hispanic patients had lower odds of adverse outcome, and female patients had greater odds of minor complication [OR 1.017, 95% CI (1.008-1.027), P < 0.001]. CONCLUSIONS Procedure-specific racial and sex-related disparities exist in emergency general surgery patients who underwent interhospital transfer. Specific interventions should be implemented to address these disparities to improve the safety of emergency procedures.
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Affiliation(s)
| | | | - Brian Martinez
- Dr Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, Florida
| | | | - Abigail Rosander
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona
| | - Lucy Kornblith
- Division of Trauma and Surgical Critical Care, Department of Surgery, Zuckerberg Hospital and Trauma Center, San Francisco, California
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida.
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Chrusciel J, Clément MC, Steunou S, Prost T, Duclos A, Sanchez S. Effect of the Implementation of the French Hospital Regionalization Policy on Patient Mobility. Health Syst Reform 2023; 9:2267256. [PMID: 37890079 DOI: 10.1080/23288604.2023.2267256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
A new law was voted in France in 2016 to increase cooperation between public sector hospitals. Hospitals were encouraged to work under the leadership of local referral centers and to share their support functions (e.g., information systems) with newly created hospital groups, called "Regional Hospital Groups." The law made it compulsory for each public sector hospital to become affiliated with one of 136 newly created hospital groups. The policy's aim was to ensure that all patients were sent to the hospital best qualified to treat their unique condition, among the hospitals available at the regional level. Therefore, we aimed to assess whether this regionalization policy was associated with changes in observed patterns of patient mobility between hospitals. This nationwide observational study followed an interrupted time series design. For each stay occurring from 2014 to 2019, we ascertained whether or not the stay was followed by mobility toward another hospital within 90 days, and whether or not the receiving hospital was part of the same Regional Hospital Group as the sender hospital. The proportion of mobility directed toward the same regional hospital group increased from 22.9% in 2014 (95% CI 22.7-23.1) to 24.6% in 2019 (95% CI 24.4-24.8). However, the absence of discontinuity during the policy change year was consistent with the hypothesis of a preexisting trend toward regionalization. Therefore, the policy did not achieve major changes in patterns of mobility between hospitals. Other objectives of the reform, including long-term consequences on the healthcare offer, remain to be assessed.
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Affiliation(s)
- Jan Chrusciel
- Department of Public Health, Hôpitaux Champagne Sud, Troyes, France
| | - Marie-Caroline Clément
- Department of Classifications in Healthcare, Medical Information and Financing Models, Technical Agency for Information on Hospital Care, Paris, France
| | - Sandra Steunou
- DATA Department, Technical Agency for Information on Hospital Care, Lyon, France
| | - Thierry Prost
- Department of Partnerships, Technical Agency for Information on Hospital Care, Lyon, France
| | - Antoine Duclos
- Research on Healthcare Performance Lab, INSERM U1290: RESHAPE, University Claude Bernard Lyon 1, Lyon, France
| | - Stéphane Sanchez
- Department of Public Health, Hôpitaux Champagne Sud, Troyes, France
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Blank J, Shiroff AM, Kaplan LJ. Surgical Emergencies in Patients with Significant Comorbid Diseases. Surg Clin North Am 2023; 103:1231-1251. [PMID: 37838465 DOI: 10.1016/j.suc.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.
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Affiliation(s)
- Jacqueline Blank
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA
| | - Adam M Shiroff
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
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8
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Silver DS, Teng C, Brown JB. Timing, triage, and mode of emergency general surgery interfacility transfers in the United States: A scoping review. J Trauma Acute Care Surg 2023; 95:969-974. [PMID: 37418697 PMCID: PMC10728349 DOI: 10.1097/ta.0000000000004011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
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.
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Affiliation(s)
- David S. Silver
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Cindy Teng
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
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9
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Lorenz W, Yang H, Paton L, Barbat S, Matthews B, Reinke CE, Schiffern L, Baimas-George M. Virtual triage from freestanding emergency departments: a propensity score-weighted analysis of short-term outcomes in emergency general surgery. Surg Endosc 2023; 37:7901-7907. [PMID: 37418149 DOI: 10.1007/s00464-023-10241-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Freestanding emergency departments (FSEDs) have generated improved hospital metrics, including decreased ED wait times and increased patient selection. Patient outcomes and process safety have not been evaluated. This study investigates the safety of FSED virtual triage in the emergency general surgery (EGS) patient population. METHODS AND PROCEDURES A retrospective review evaluated all adult EGS patients admitted to a community hospital between January 2016 and December 2021 who either presented at a FSED and received virtual evaluation from a surgical team (fEGS) or presented at the community hospital emergency department and received in-person evaluation from the same surgical group (cEGS). Patients' demographics, acute care utilization history, and clinical characteristics at the onset of the index visit were used to build a propensity score model and stabilized Inverse Probability of Treatment Weights (IPTW) were used to create a weighted sample. Multivariable regression models were then employed to the weighted sample to evaluate the treatment effect of virtual triage compared to in-person evaluation on short-term outcomes, including length of stay (LOS) and 30-day readmission and mortality. Variables which occurred during the index visit (such as surgery duration and type of surgery) were adjusted for in the multivariable analyses. RESULTS Of 1962 patients, 631 (32.2%) were initially evaluated virtually (fEGS) and 1331 (67.8%) underwent an in-person evaluation (cEGS). Baseline characteristics demonstrated significant differences between the cohorts in gender, race, payer status, BMI, and CCI score. Baseline risks were well balanced in the IPTW-weighted sample (SD range 0.002-0.18). Multivariable analysis found no significant differences between the balanced cohorts in 30-day readmission, 30-day mortality, and LOS (p > 0.05 for all). CONCLUSION Patients who undergo virtual triage have similar outcomes to those who undergo in-person triage for EGS diagnoses. Virtual triage at FSED for these EGS patients may be an efficient and safe means for initial evaluation.
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Affiliation(s)
- William Lorenz
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Hongmei Yang
- Atrium Health, Information and Analytics Services, 720 East Morehead St, Charlotte, NC, 28203, USA
| | - Lauren Paton
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Selwan Barbat
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brent Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Lynnette Schiffern
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Maria Baimas-George
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
- Carolinas Medical Center, 1025 Morehead Medical Plaza, Suite #300, Charlotte, NC, 28204, USA.
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10
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Mueller S, Murray M, Goralnick E, Kelly C, Fiskio JM, Yoon C, Schnipper JL. Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study. BMJ Open Qual 2023; 12:e002518. [PMID: 37899076 PMCID: PMC10619021 DOI: 10.1136/bmjoq-2023-002518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 10/31/2023] Open
Abstract
IMPORTANCE The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange. OBJECTIVE To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes. DESIGN Prospective interventional cohort study. SETTING A 792-bed tertiary care hospital. PARTICIPANTS All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022. INTERVENTIONS A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre. MAIN OUTCOMES AND MEASURES Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission. RESULTS Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality. CONCLUSIONS AND RELEVANCE Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes.
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Affiliation(s)
- Stephanie Mueller
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Murray
- Patient Transfer and Access Center, MassGeneral Brigham Healthcare System, Boston, MA, USA
| | - Eric Goralnick
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Caitlin Kelly
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie M Fiskio
- MassGeneral Brigham HealthCare System Inc, Boston, Massachusetts, USA
| | - Cathy Yoon
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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11
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Barthold LK, Burney CP, Baumann LE, Briggs A. Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience. J Surg Res 2023; 283:640-647. [PMID: 36455417 DOI: 10.1016/j.jss.2022.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. MATERIALS AND METHODS We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. RESULTS Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). CONCLUSIONS At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.
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Affiliation(s)
- Laura K Barthold
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laura E Baumann
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexandra Briggs
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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12
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Iantorno SE, Bucher BT, Horns JJ, McCrum ML. Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States. J Trauma Acute Care Surg 2023; 94:371-378. [PMID: 36472477 PMCID: PMC10008022 DOI: 10.1097/ta.0000000000003856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Differential access to specialty surgical care can drive health care disparities, and interhospital transfer (IHT) is one mechanism through which access barriers can be realized for vulnerable populations. The association between race/ethnicity and IHT for patients presenting with complex emergency general surgery (EGS) disease is understudied. METHODS Using the 2019 Nationwide Emergency Department Sample, we identified patients 18 years and older with 1 of 13 complex EGS diseases based on International Classification of Diseases, Tenth Revision , diagnosis codes. The primary outcome was IHT. A series of weighted logistic regression models was created to determine the association of race/ethnicity with the primary outcome while controlling for patient and hospital characteristics. RESULTS Of 387,610 weighted patient encounters from 989 hospitals, 59,395 patients (15.3%) underwent IHT. Compared with non-Hispanic White patients, rates of IHT were significantly lower for non-Hispanic Black (15% vs. 17%; unadjusted odds ratio (uOR) [95% confidence interval (CI)], 0.58 [0.49-0.68]; p < 0.001), Hispanic/Latinx (HL) (9.0% vs. 17%; uOR [95% CI], 0.48 [0.43-0.54]; p < 0.001), Asian/Pacific Islander (Asian/PI) (11% vs. 17%; uOR [95% CI], 0.84 [0.78-0.91]; p < 0.001), and other race/ethnicity (12% vs. 17%; uOR [95% CI], 0.68 [0.57-0.81]; p < 0.001) patients. In multivariable models, the adjusted odds of IHT remained significantly lower for HL (adjusted odds ratio [95% CI], 0.76 [0.72-0.83]; p < 0.001) and Asian/PI patients (adjusted odds ratio [95% CI], 0.73 [0.62-0.86]; p < 0.001) but not for non-Hispanic Black and other race/ethnicity patients ( p > 0.05). CONCLUSION In a nationally representative sample of emergency departments across the United States, patients of minority race/ethnicity presenting with complex EGS disease were less likely to undergo IHT when compared with non-Hispanic White patients. Disparities persisted for HL and Asian/PI patients when controlling for comorbid conditions, hospital and residential geography, neighborhood socioeconomic status, and insurance; these patients may face unique barriers in accessing surgical care. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Stephanie E. Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Brian T. Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Joshua J Horns
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Marta L. McCrum
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
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13
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Robinson A, Kornelsen J. Documenting surgical triage in rural surgical networks: Formalising existing structures. Aust J Rural Health 2022; 30:643-653. [PMID: 35802800 PMCID: PMC9795974 DOI: 10.1111/ajr.12888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 02/14/2022] [Accepted: 05/09/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection. DESIGN Participants participated in a series of semi-structured in-depth interviews which were coded and underwent thematic analysis. SETTING Six community hospitals in British Columbia, Canada. PARTICIPANTS General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists. RESULTS Based on participant accounts, rural surgical and obstetrical decision-making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources. CONCLUSION Decision-making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific.
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Affiliation(s)
- Alana Robinson
- Melbourne Medical SchoolUniversity of MelbourneMelbourneVICAustralia
| | - Jude Kornelsen
- Centre for Rural Health Research, Department of Family PracticeUniversity of British ColumbiaVancouverBCCanada
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14
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Han JS, Yuan E, Bonney PA, Lin M, Reckamp K, Ding L, Zada G, Mack WJ, Attenello FJ. Interhospital transfer of patients with malignant brain tumors undergoing resection is associated with routine discharge. Clin Neurol Neurosurg 2022; 221:107372. [DOI: 10.1016/j.clineuro.2022.107372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022]
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15
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The physiology of failure: Identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record. J Trauma Acute Care Surg 2022; 93:409-417. [PMID: 35998289 DOI: 10.1097/ta.0000000000003618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients have increased mortality risk compared with elective counterparts. Recent studies on risk factors have largely used national data sets limited to administrative data. Our aim was to examine risk factors in an integrated regional health system EGS database, including clinical and administrative data, hypothesizing that this novel process would identify clinical variables as important risk factors for mortality. METHODS Our nine-hospital health system's billing data were queried for EGS International Classification of Disease codes between 2013 and 2018. Codes were grouped by diagnosis, and urgent or emergent encounters were included and merged with electronic medical record clinical data. Outcomes assessed were inpatient and 1-year mortality. Standard and multivariable statistics evaluated factors associated with mortality. RESULTS There were 253,331 EGS admissions with 3.6% inpatient mortality rate. Patients who suffered inpatient and 1-year mortality were older, more likely to be underweight, and have neutropenia or elevated lactate. On multivariable analysis for inpatient mortality: age (odds ratio [OR], 1.7-6.7), underweight body mass index (OR, 1.6), transfer admission (OR, 1.8), leukopenia (OR, 2.0), elevated lactate (OR, 1.8), and ventilator requirement (OR, 7.1) remained associated with increased risk. Adjusted analysis for 1-year mortality demonstrated similar findings, with highest risk associated with older age (OR, 2.8-14.6), underweight body mass index (OR, 2.3), neutropenia (OR, 2.0), and tachycardia (OR, 1.7). CONCLUSION After controlling for patient and disease characteristics available in administrative databases, clinical variables remained significantly associated with mortality. This novel yet simple process allows for easy identification of clinical data points imperative to the study of EGS diagnoses that are critical in understanding factors that impact mortality. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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16
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Interfacility Transfer for Nonelective Cholecystectomy in High MELD Patients: An ACS-NSQIP Analysis. J Surg Res 2022; 279:127-134. [PMID: 35759930 DOI: 10.1016/j.jss.2022.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Interfacility transfer to a referral center is often considered for patients with liver disease undergoing nonelective cholecystectomy given management complexities and perioperative risk. We sought to determine the association between the Model for End Stage Liver Disease (MELD) score, transfer frequency, and outcomes in those patients using a national database. MATERIALS AND METHODS The ACS-NSQIP participant use files were queried for nonelective open or laparoscopic cholecystectomy from 2016 to 2018. Patients were grouped according to low (6-11), intermediate (12-18), or high (>18) MELD. In the high MELD group, patient characteristics and outcomes were compared between transferred and nontransferred patients and multivariate regression was performed to evaluate independent predictors of outcomes. Outcomes included in-hospital mortality, complications, length-of-stay (LOS), and 30-d reoperation and readmission. RESULTS 30,171 subjects were included. Transfer was more likely as MELD increased (19.5% high versus 12.1% low, P < 0.001). High MELD patients had increased LOS, reoperation, readmission, and mortality rates compared to low MELD. In high MELD patients (n = 1016), those transferred were more likely older, white, obese, and septic. Transferred patients had increased mortality (7.6% versus 4.2%, P = 0.044), LOS, reoperation, and complications. After controlling for differences between transferred and nontransferred patients, transfer status was not independently associated with mortality (OR = 1.593, P = 0.177), postoperative complications or LOS, but was associated with increased risk for reoperation. Sepsis and laparoscopic surgery were independently associated with higher and lower mortality, respectively. CONCLUSIONS Transfer status is not independently associated with mortality, postoperative complications, or prolonged LOS, suggesting patients with advanced liver disease undergoing acute cholecystectomy may not benefit from interfacility transfer.
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17
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Young E, Khoo TW, Trochsler MI, Maddern GJ. Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis. ANZ J Surg 2022; 92:1314-1321. [PMID: 35437859 DOI: 10.1111/ans.17718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 04/02/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients. METHODS A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of >16. Articles were critically appraised and data were extracted into a pre-specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead. RESULTS Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non-emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances. CONCLUSION There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well-designed prospective cohort studies are required to bridge this knowledge gap.
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Affiliation(s)
- Edward Young
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Teng-Wei Khoo
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Markus Ivo Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy John Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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18
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Predicting Outcomes for Interhospital Transferred Patients of Emergency General Surgery. Crit Care Res Pract 2022; 2022:8137735. [PMID: 35463803 PMCID: PMC9033401 DOI: 10.1155/2022/8137735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/18/2022] [Indexed: 11/18/2022] Open
Abstract
Background. Interhospital transferred (IHT) emergency general surgery (EGS) patients are associated with high care intensity and mortality. However, prior studies do not focus on patient-level data. Our study, using each IHT patient’s data, aimed to understand the underlying cause for IHT EGS patients’ outcomes. We hypothesized that transfer origin of EGS patients impacts outcomes due to critical illness as indicated by higher Sequential Organ Failure Assessment (SOFA) score and disease severity. Materials and Methods. We conducted a retrospective analysis of all adult patients transferred to our quaternary academic center’s EGS service from 01/2014 to 12/2016. Only patients transferred to our hospital with EGS service as the primary service were eligible. We used multivariable logistic regression and probit analysis to measure the association of patients’ clinical factors and their outcomes (mortality and survivors’ hospital length of stay [HLOS]). Results. We analyzed 708 patients, 280 (39%) from an ICU, 175 (25%) from an ED, and 253 (36%) from a surgical ward. Compared to ED patients, patients transferred from the ICU had higher mean (SD) SOFA score (5.7 (4.5) vs. 2.39 (2),
), longer HLOS, and higher mortality. Transferring from ICU (OR 2.95, 95% CI 1.36–6.41,
), requiring laparotomy (OR 1.96, 95% CI 1.04–3.70,
), and SOFA score (OR 1.22, 95% CI 1.13–1.32,
) were associated with higher mortality. Conclusions. At our academic center, patients transferred from an ICU were more critically ill and had longer HLOS and higher mortality. We identified SOFA score and a few conditions and diagnoses as associated with patients’ outcomes. Further studies are needed to confirm our observation.
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19
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Emergency General Surgery Transfer and Effect on Inpatient Mortality and Post-Discharge Emergency Department Visits: A Propensity Score Matched Analysis. J Am Coll Surg 2022; 234:737-746. [PMID: 35426384 DOI: 10.1097/xcs.0000000000000146] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Invited Commentary: To Transfer or Not? Outcomes in Emergency General Surgery. J Am Coll Surg 2022; 234:746-747. [DOI: 10.1097/xcs.0000000000000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Ghneim MH, Sadler CA, Kufera JA, Hendrix CJ, Herrold JA, Clark J, O'Meara LB, Diaz JJ. Cost Differences Between Teaching and Nonteaching Hospitals for Older Adults Requiring Emergency General Surgery Procedures in the State of Maryland. Am Surg 2022; 88:1783-1791. [PMID: 35377258 DOI: 10.1177/00031348221083948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs). METHODS A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality. RESULTS Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, P<.001) compared to NTHs. Lysis of adhesions, cholecystectomy, and PC comprised the overall most common EGSPs. Older adults at THs incurred comparatively higher median hospital charges for every EGSP due to increased room charges and LOS. Mortality was higher at THs (6.13% vs 5.33%, P<.001). CONCLUSION While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.
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Affiliation(s)
- Mira H Ghneim
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Craig A Sadler
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph A Kufera
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.,National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, Baltimore, MD, USA
| | - Cheralyn J Hendrix
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph A Herrold
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jaclyn Clark
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Lindsay B O'Meara
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jose J Diaz
- University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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22
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Young E, Kopunic HS, Trochsler MI, Maddern GJ. Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study. ANZ J Surg 2022; 92:1322-1331. [PMID: 35373494 DOI: 10.1111/ans.17669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. METHODS Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. RESULTS After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P <0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P <0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P = 0.0035). CONCLUSION In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.
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Affiliation(s)
- Edward Young
- The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Helena S Kopunic
- Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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23
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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Coimbra R, Barrientos R, Allison-Aipa T, Zakhary B, Firek M. The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter. J Trauma Acute Care Surg 2022; 92:296-304. [PMID: 35081097 DOI: 10.1097/ta.0000000000003463] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The impact of interhospital transfer on outcomes of patients undergoing emergency general surgery (EGS) procedures is incompletely studied. We set out to determine if transfer before definitive surgical care leads to worse outcomes in EGS patients. METHODS Using the National Surgical Quality Improvement Project database (2013-2019), a retrospective cohort study was conducted including nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Time to surgery was recorded in days. The impact of interhospital transfer on outcomes (mortality, major complications, 30-day reoperations, and 30-day readmissions) and length of stay, according to procedure risk and time to surgery, were analyzed by multivariate logistic regression and inverse probability treatment of the weighting with treatment effect in the treated. RESULTS A total of 329,613 patients were included in the study (284,783 direct admission and 44,830 transfers). Adjusted mortality (3.1% vs. 10.4%; adjusted odds ratio [AOR], 1.28; p < 0.001), major complications (6.7% vs. 18.9%; AOR, 1.39; p < 0.001), 30-day reoperations (3.1% vs. 6.4%; AOR, 1.22; p < 0.001), and length of stay (2 vs. 5) were higher in transferred patients. Transfer had no effect on 30-day readmissions (6% vs. 8.5%; AOR, 1.04; p = 0.063). These results were also observed in high-risk surgery patients and in the late surgery group. The results were further confirmed after robust propensity score weighting was performed. CONCLUSION We have demonstrated that delays to surgical intervention affect outcomes and that interhospital transfer of EGS patients for definitive surgical care has a negative impact on mortality, development of postoperative complications, and reoperations in patients undergoing high-risk EGS procedures. These findings may have important implications for regionalization of EGS care. LEVEL OF EVIDENCE Prognostic/epidemiological, level III.
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Affiliation(s)
- Raul Coimbra
- From the Comparative Effectiveness and Clinical Outcomes Research Center (R.C., R.B., T.A.-A., B.Z., M.F.), Riverside University Health System Medical Center, Moreno Valley, California; Department of Surgery (R.C., T.A.-A.), Loma Linda University School of Medicine, Loma Linda, California; University of California Riverside School of Medicine (R.B.), Riverside, California
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Chapman EK, Doctor T, Gal JS, Shuman WH, Neifert SN, Martini ML, McNeill IT, Rothrock RJ, Schupper AJ, Caridi JM. The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis. Spine (Phila Pa 1976) 2021; 46:1535-1541. [PMID: 34027927 DOI: 10.1097/brs.0000000000004127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. METHODS Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. RESULTS Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). CONCLUSION Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan S Gal
- Department of Anesthesia, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Teng CY, Davis BS, Kahn JM, Rosengart MR, Brown JB. Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts. Surgery 2021; 170:1298-1307. [PMID: 34147261 PMCID: PMC8550996 DOI: 10.1016/j.surg.2021.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.
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Affiliation(s)
- Cindy Y Teng
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Billie S Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. https://twitter.com/joshua_b_brown
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AlSowaiegh R, Naar L, El Moheb M, Parks JJ, Fawley J, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA. The Emergency Surgery Score is a powerful predictor of outcomes across multiple surgical specialties: Results of a retrospective nationwide analysis. Surgery 2021; 170:1501-1507. [PMID: 34176601 DOI: 10.1016/j.surg.2021.05.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/11/2021] [Accepted: 05/20/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Emergency Surgery Score was recently validated in a prospective multicenter study as an accurate predictor of mortality in emergency general surgery patients. The Emergency Surgery Score is easily calculated using multiple demographic, comorbidity, laboratory, and acuity of disease variables. We aimed to investigate whether the Emergency Surgery Score can predict 30-day postoperative mortality across patients undergoing emergency surgery in multiple surgical specialties. METHODS Our study is a retrospective cohort study using data from the national American College of Surgeons National Surgical Quality Improvement Program database (2007-2017). We included patients that underwent emergency gynecologic, urologic, thoracic, neurosurgical, orthopedic, vascular, cardiac, and general surgical procedures. The Emergency Surgery Score was calculated for each patient, and the correlation between the Emergency Surgery Score and 30-day mortality was assessed for each specialty using the c-statistics methodology. RESULTS Of 6,485,915 patients, 173,890 patients were included. The mean age was 60 years, 50.6% were female patients, and the overall mortality was 9.7%. The Emergency Surgery Score predicted mortality best in emergency gynecologic, general, and urologic surgery (c-statistics: 0.97, 0.87, 0.81, respectively). The Emergency Surgery Score predicted mortality moderately well in emergency thoracic, neurosurgical, orthopedic, and vascular surgery (c-statistics 0.73-0.79). For example, the mortality of gynecology patients with an Emergency Surgery Score of 5, 9, and 13 was 2%, 27%, and 50%, respectively. The Emergency Surgery Score performed poorly in cardiac surgery. CONCLUSION The Emergency Surgery Score accurately predicts mortality across patients undergoing emergency surgery in multiple surgical specialties, especially general, gynecologic, and urologic surgery. The Emergency Surgery Score can prove useful for perioperative patient counseling and for benchmarking the quality of surgical care.
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Affiliation(s)
- Reem AlSowaiegh
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Current opinion on emergency general surgery transfer and triage criteria. J Trauma Acute Care Surg 2021; 89:e71-e77. [PMID: 32467469 DOI: 10.1097/ta.0000000000002806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Fernandes-Taylor S, Yang DY, Schumacher J, Ljumani F, Fertel BS, Ingraham A. Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments. Am J Emerg Med 2020; 40:83-88. [PMID: 33360394 DOI: 10.1016/j.ajem.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States. METHOD We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital. RESULTS Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals. CONCLUSION Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.
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Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Jessica Schumacher
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Fiona Ljumani
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Baruch S Fertel
- Emergency Services Institute & Enterprise Quality and Safety Cleveland Clinic, Cleveland OH, United States of America
| | - Angela Ingraham
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
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Ingraham A, Reinke CE. Optimizing Safety for Surgical Patients Undergoing Interhospital Transfer. Surg Clin North Am 2020; 101:57-69. [PMID: 33212080 DOI: 10.1016/j.suc.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Interhospital transfers play a key role in ensuring that patients receive necessary care. However, patients who are transferred between hospitals are a vulnerable population, and outcomes of transferred patients are suboptimal. Despite the critical nature of interhospital transfers, only limited effort has been dedicated to standardization and improvement of the transfer process. Studying and adapting quality improvement efforts directed at other transitions of care, particularly those that cross between different facilities and care teams "such as the transition from hospital to home or extended care facilities" may improve the care of surgical patients transferred between acute care institutions.
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Affiliation(s)
- Angela Ingraham
- Department of Surgery, University of Wisconsin-Madison, G5/342 CSC, 600 Highland Avenue, Madison, WI 53792, USA. https://twitter.com/AngieIngrahamMD
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA.
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Bruenderman EH, Block SB, Kehdy FJ, Benns MV, Miller KR, Motameni A, Nash NA, Bozeman MC, Martin RCG. An evaluation of emergency general surgery transfers and a call for standardization of practices. Surgery 2020; 169:567-572. [PMID: 33012562 PMCID: PMC7528972 DOI: 10.1016/j.surg.2020.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is an increasing trend toward regionalization of emergency general surgery, which burdens patients. The absence of a standardized, emergency general surgery transfer algorithm creates the potential for unnecessary transfers. The aim of this study was to evaluate clinical reasoning prompting emergency general surgery transfers and to initiate a discussion for optimal emergency general surgery use. METHODS Consecutive emergency general surgery transfers (December 2018 to May 2019) to 2 tertiary centers were prospectively enrolled in an institutional review board-approved protocol. Clinical reasoning prompting transfer was obtained prospectively from the accepting/consulting surgeon. Patient outcomes were used to create an algorithm for emergency general surgery transfer. RESULTS Two hundred emergency general surgery transfers (49% admissions, 51% consults) occurred with a median age of 59 (18 to 100) and body mass index of 30 (15 to 75). Insurance status was 25% private, 45% Medicare, 21% Medicaid, and 9% uninsured. Weekend transfers (Friday to Sunday) occurred in 45%, and 57% occurred overnight (6:00 pm to 6:00 am). Surgeon-to-surgeon communication occurred with 22% of admissions. Pretransfer notification occurred with 10% of consults. Common transfer reasons included no surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). A minority (36%) underwent surgery within 24 hours; 54% did not require surgery during the admission. Median length of stay was 6 (1 to 44) days. CONCLUSION Conditions prompting emergency general surgery transfers are heterogeneous in this rural state review. There remains an unmet need to standardize emergency general surgery transfer criteria, incorporating patient and hospital factors and surgeon availability. Well-defined requirements for communication with the accepting surgeon may prevent unnecessary transfers and maximize resource allocation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, KY.
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Survival curve identifies critical period for postoperative mortality in cardiac patients undergoing emergency general surgery. Sci Rep 2020; 10:15499. [PMID: 32968193 PMCID: PMC7512003 DOI: 10.1038/s41598-020-72647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/31/2020] [Indexed: 11/09/2022] Open
Abstract
The number of non-cardiac major surgeries carried out has significantly increased in recent years to around 200 million procedures carried out annually. Approximately 30% of patients submitted to non-cardiac surgery present some form of cardiovascular comorbidity. In emergency situations, with less surgery planning time and greater clinical severity, the risks become even more significant. The aim of this study is to determine the incidence and clinical outcomes in patients with cardiovascular disease submitted to non-cardiac surgical procedures in a single cardiovascular referral center. This is a prospective cohort study of patients with cardiovascular disease submitted to non-cardiovascular surgery. All procedures were carried out by the same surgeon, between January 2006 and January 2018. 240 patients included were elderly, 154 were male (64%), 8 patients presented two diagnoses. Of the resulting 248 procedures carried out, 230 were emergency (92.8%). From the data obtained it was possible to estimate the day from which the occurrence of mortality is less probable in the postoperative phase. Our research evaluated the epidemiological profile of the surgeries and we were able to estimate the survival and delimit the period of greatest risk of mortality in these patients. The high rate of acute mesenteric ischemia was notable, a serious and frequently fatal condition.
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Georgino MM, Murphy K, Paton BL, Schiffern L, Ross SW, Reinke CE. Association between interhospital transfer and morbid obesity in emergency general surgery procedures. Am J Surg 2020; 220:1290-1295. [PMID: 32731957 DOI: 10.1016/j.amjsurg.2020.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/11/2020] [Accepted: 06/25/2020] [Indexed: 12/07/2022]
Abstract
BACKGROUND Obese patients may have unique surgical needs. The goal of this study is to determine if there is an association between obesity and transfer in patients undergoing EGS. METHODS EGS patients were identified in the NSQIP 2011-2016 database. Outcome variables included interhospital transfer, days to surgery, SSI, postoperative LOS, discharge destination, and 30-day readmission. Descriptive statistics and multivariable regression were utilized. RESULTS 419,373 EGS patients were identified, and transfer status varied by obesity class. After controlling for other factors, obese patients had increased odds of interhospital transfer (OR = 1.07-1.53), SSI (OR = 1.22-1.69), and decreased odds of discharge to home (OR = 0.42-0.71, all p < 0.01) but not of 30-day readmission or delay from admission to surgical intervention. CONCLUSIONS Obese patients undergoing EGS procedures have an increased likelihood of transfer from an acute care hospital. As obese EGS patients are increasingly prevalent, determining best triage practices for this unique patient population warrants additional investigation.
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Affiliation(s)
- Madeline M Georgino
- Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Plaza Suite 300, Charlotte, NC, 28204, USA.
| | - Keith Murphy
- Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Plaza Suite 300, Charlotte, NC, 28204, USA.
| | - B Lauren Paton
- Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Plaza Suite 300, Charlotte, NC, 28204, USA.
| | - Lynn Schiffern
- Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Plaza Suite 300, Charlotte, NC, 28204, USA.
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Plaza Suite 300, Charlotte, NC, 28204, USA.
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Plaza Suite 300, Charlotte, NC, 28204, USA.
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Mitchell A, Drevets P, Ramsey W, Holsten S. Distance from Hospital and Surgical Outcomes in Emergency General Surgery. Am Surg 2020. [DOI: 10.1177/000313481908500918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Philip JL, Yang DY, Wang X, Fernandes-Taylor S, Hanlon BM, Schumacher J, Saucke MC, Havlena J, Santry HP, Ingraham AM. Effect of Transfer Status on Outcomes of Emergency General Surgery Patients. Surgery 2020; 168:280-286. [PMID: 32456785 DOI: 10.1016/j.surg.2020.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/02/2020] [Accepted: 01/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database. METHODS We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design. RESULTS We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay. CONCLUSIONS EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.
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Affiliation(s)
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Xing Wang
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Bret M Hanlon
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Megan C Saucke
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Heena P Santry
- Department of Surgery, Ohio State University, Columbus, OH
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Risk Prediction Accuracy Differs for Transferred and Nontransferred Emergency General Surgery Cases in the ACS-NSQIP. J Surg Res 2019; 247:364-371. [PMID: 31767278 DOI: 10.1016/j.jss.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/09/2019] [Accepted: 10/01/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Risk prediction accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator has been shown to differ between emergency and elective surgery. Benchmarking methods of clinical performance require accurate risk estimation, and current methods rarely account for admission source; therefore, our goal was to assess whether the ACS-NSQIP predicts mortality comparably between transferred and nontransferred emergency general surgery (EGS) cases. MATERIALS AND METHODS This is a retrospective study using the ACS-NSQIP database from 2005 to 2014including all inpatients who underwent one of seven previously described EGS procedures. The admission source was classified as directly admitted versus transferred from an outside emergency room or an acute care facility. We compared the accuracy of ACS-NSQIP-predicted mortality probabilities using the observed-to-expected (O:E) ratio and Brier score. A subgroup analysis was performed to compare accuracy of high-risk and low-risk procedures. RESULTS A total of 206,103 EGS admissions were identified, of which 6.97% were transfers. Overall mortality was 3.26% for the entire cohort and 10.24% within the transfer group. The O:E ratios generated by ACS-NSQIP models differed between transferred patients (O:E = 1.0, 95% confidence interval = 0.97-1.02) and nontransferred patients (O:E = 1.12, 95% confidence interval = 1.09-1.14). The Brier score for transferred patients was greater than that for nontransferred patients (0.063 versus 0.018, respectively) showing higher accuracy for nontransferred patients. CONCLUSIONS The ACS-NSQIP risk estimates used for benchmarking differ between transferred and nontransferred EGS cases. Analyses of the Brier score by the ACS-NSQIP risk calculator demonstrated inferior prediction for transferred patients. This increased burden on accepting institutions will have an impact on quality metrics and should be considered for benchmarking of clinical performance.
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Castillo-Angeles M, Uribe-Leitz T, Jarman M, Jin G, Feeney T, Salim A, Havens JM. Transferred Emergency General Surgery Patients Are at Increased Risk of Death: A NSQIP Propensity Score Matched Analysis. J Am Coll Surg 2019; 228:871-877. [DOI: 10.1016/j.jamcollsurg.2019.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/24/2018] [Accepted: 01/22/2019] [Indexed: 11/28/2022]
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Cost Burden and Mortality in Rural Emergency General Surgery Transfer Patients. J Surg Res 2019; 234:60-64. [DOI: 10.1016/j.jss.2018.08.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/13/2018] [Accepted: 08/24/2018] [Indexed: 11/18/2022]
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Interhospital transfer for emergency general surgery: An independent predictor of mortality. Am J Surg 2018; 216:787-792. [DOI: 10.1016/j.amjsurg.2018.07.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/24/2018] [Accepted: 07/17/2018] [Indexed: 11/23/2022]
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