Emergency general surgery

In 2015, the United States moved from the International Classification of Diseases, Ninth Revision ( ICD-9 ), to the International Classification of Diseases, Tenth Revision ( ICD-10 ), coding system. The American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes previously established a list of ICD-9 diagnoses to define the field of emergency general surgery (EGS). This study evaluates the general equivalence mapping (GEM) crosswalk to generate an equivalent list of ICD-10 -coded EGS diagnoses. The GEM was used to generate a list of ICD-10 codes corresponding to the American Association for the Surgery of Trauma ICD-9 EGS diagnosis codes. These individual ICD-9 and ICD-10 codes were aggregated by surgical area and diagnosis groups. The volume of patients admitted with these diagnoses in the National Inpatient Sample in the ICD-9 era (2013-2014) was compared with the ICD-10 volumes to generate observed to expected ratios. The crosswalk was manually reviewed to identify the causes of discrepancies between the ICD-9 and ICD-10 lists. There were 485 ICD-9 codes, across 89 diagnosis categories and 11 surgical areas, which mapped to 1,206 unique ICD-10 codes. A total of 196 (40%) ICD-9 codes have an exact one-to-one match with an ICD-10 code. The median observed to expected ratio among the diagnosis groups for a primary diagnosis was 0.98 (interquartile range, 0.82-1.12). There were five key issues identified with the ability of the GEM to crosswalk ICD-9 EGS diagnoses to ICD-10 : (1) changes in admission volumes, (2) loss of necessary modifiers, (3) lack of specific ICD-10 code, (4) mapping to a different condition, and (5) change in coding nomenclature. The GEM provides a reasonable crosswalk for researchers and others to use when attempting to identify EGS patients in with ICD-10 diagnosis codes. However, we identify key issues and deficiencies, which must be accounted for to create an accurate patient cohort. This is essential for ensuring the validity of policy, quality improvement, and clinical research work anchored in ICD-10 coded data. Diagnostic Test/Criteria; Level III.

Acute care surgery services continue expanding to provide emergency general surgery (EGS) care. The aim of this study is to define the characteristics of the EGS population in Maryland. Retrospective review of the Health Services Cost Review Commission database from 2009 to 2013 was performed. American Association for the Surgery of Trauma-defined EGS ICD-9 codes were used to define the EGS population. Data collected included patient demographics, admission origin [emergency department (ED) versus non-ED], length of stay (LOS), mortality, and disposition. There were 3,157,646 encounters. In all, 817,942 (26%) were EGS encounters, with 76 per cent admitted via an ED. The median age of ED patients that died was 74 years versus 61 years for those that lived (P < 0.001). Twenty one per cent of ED admitted patients had a LOS > 7 days. Of 78,065 non-ED admitted patients, the median age of those that died was 68 years versus 59 years for those that lived (P < 0.001). Twenty eight per cent of non-ED admits had LOS > 7 days. In both ED and non-ED patients, there was a bimodal distribution of death, with most patients dying at LOS ≤ 2 or LOS > 7 days. In this study, EGS diagnoses are present in 26 per cent of inpatient encounters in Maryland. The EGS population is elderly with prolonged LOS and a bimodal distribution of death.

Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist. To define readmission rates and identify risk factors for readmission after common EGS procedures. Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis. Thirty-day hospital readmission. Among 177,511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adjusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%). Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.

Fragmentation of care (FOC) is defined as readmission to a nonindex hospital and can be associated with worse outcomes among emergency general surgery (EGS) patients. This study assessed hospital characteristics associated with patterns of FOC in EGS patients and the effect of interfacility transfer after FOC on mortality. Using the Nationwide Readmissions Database 2019, we included patients 18 years or older who were admitted to an index hospital with an EGS diagnosis managed operatively and had an emergency readmission within 90 days. Patients were classified into 4 patterns of fragmentation: no FOC, FOC, defragmented care (readmitted to a nonindex hospital, then transferred back), and hyperfragmented care (readmitted to a nonindex hospital, then transferred to another nonindex hospital). Patient severity of illness was defined using severity of illness categories of All Patient-Refined Diagnosis Related Groups (APR-DRG). Multivariable logistic regression analyses were used to identify hospital characteristics associated with FOC and the effect of FOC on 90-day mortality. Of 26,100 patients included, 82.5% had no FOC, 16.4% had FOC, 0.3% had defragmented care, and 0.9% had hyperfragmented care. Index hospital characteristics associated with FOC were small size (by number of beds), private investor or government owned, and low EGS volumes. Controlling for hospital and patient characteristics, FOC (odds ratio 1.22; 95% CI 1.01 to 1.47; p = 0.045) was significantly associated with increased 90-day mortality, driven by those with major or extreme severity of illness of APR-DRGs (odds ratio 1.36; 95% CI 1.13 to 1.64; p = 0.001). FOC is associated with worse outcomes in EGS patients. This study highlights the impact of FOC and the hospital characteristics associated with FOC, highlighting the need for further investigation into EGS systems of care.

Emergency general surgery procedures in hematopoietic stem cell transplant recipients

Given the high mortality and morbidity of emergency general surgery (EGS), designing and implementing effective quality assessment tools is imperative. Currently accepted EGS risk scores are limited by the need for manual extraction, which is time-intensive and costly. We developed an automated institutional electronic health record (EHR)-linked EGS registry that calculates a modified Emergency Surgery Score (mESS) and a modified Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) score and demonstrated their use in benchmarking outcomes. The EHR-linked EGS registry was queried for patients undergoing emergent laparotomies from 2018 to 2023. Data captured included demographics, admission and discharge data, diagnoses, procedures, vitals, and laboratories. The mESS and modified POTTER (mPOTTER) were calculated based off previously defined variables, with estimation of subjective variables using diagnosis codes and other abstracted treatment variables. This was validated against ESS and the POTTER risk calculators by chart review. Observed versus expected (O:E) 30-day mortality and complication ratios were generated. The EGS registry captured 177 emergent laparotomies. There were 32 deaths (18%) and 79 complications (45%) within 30 days of surgery. For mortality, the mean difference between the mESS and ESS risk predictions for mortality was 3% (SD, 10%) with 86% of mESS predictions within 10% of ESS. The mean difference between the mPOTTER and POTTER was -2% (SD, 11%) with 76% of mPOTTER predictions within 10% of POTTER. Observed versus expected ratios by mESS and ESS were 1.45 and 1.86, respectively, and for mPOTTER and POTTER, they were 1.45 and 1.30, respectively. There was similarly good agreement between automated and manual risk scores in predicting complications. Our study highlights the effective implementation of an institutional EHR-linked EGS registry equipped to generate automated quality metrics. This demonstrates potential in enhancing the standardization and assessment of EGS care while mitigating the need for extensive human resources investment. Prognostic and Epidemiologic Study; Level IV.

Creation and Implementation of an Emergency General Surgery Registry Modeled after the National Trauma Data Bank

The Healthcare Economics Committee of the American Association for the Surgery of Trauma has published a series of three articles on the topic of value in acute care surgery (ACS). In this series, the key elements of value, cost and outcomes, and the impact of stakeholder perspective on what constitutes high-value care are discussed. The fourth article in this series continues the discussion by focusing on the unique economic value that an ACS service brings to a hospital system and its patients. Characterized by the immediate 24-hour availability of surgeons trained in trauma management, emergency general surgery, and surgical critical care, acute care surgeons extend the benefits of surgical rescue and critical care to all hospitalized patients. As such, an ACS service acts as a vital part of a hospital's infrastructure to successfully care for complex and seriously ill patients, in addition to enabling the establishment of other, high revenue-generating services such as vascular, transplant, and complex oncologic surgery programs. The trauma service acts as intake for patients that lead to downstream revenue creation by other disciplines such as orthopedic and neurological surgery, while trauma center designation itself results in dedicated state funding to ensure trauma readiness in many states in the United States. The traditional "value equation" in health care of outcomes achieved per dollar spent is ill-suited to capture many of these unique aspects and benefits of ACS. This article provides the background to understand the economic value of an ACS service and future directions toward improving overall value of care.

Procedures in the intensive care unit (ICU) have traditionally been limited to short procedures that can be performed using only local anesthesia. With the advent of the field of acute care surgery – a blend of trauma, emergency general surgery, and surgical critical care – instances have evolved in which operating in the ICU is not only possible but also necessary. Increased recognition of abdominal compartment syndrome and the use of damage control strategies in both trauma and non-trauma patients have contributed to this change. In general, two types of procedures are performed in the ICU: lifesaving procedures for which a patient is too unstable to attempt transfer to the operating room and uncomplicated procedures for which transfer to the operating room seems unwarranted. Careful organization and preparation with a multidisciplinary team are crucial to ensure patient and clinician safety in both elective and emergent procedures.

Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure. A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool. The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%). The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery

Division of Traumatology, Surgical Critical Care and Emergency Surgery Penn Presbyterian Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania The authors declare no conflicts of interest.

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Concern over lack of resident interest caused by the nonoperative nature and compromised lifestyle associated with a career as a "trauma surgeon" has led to the emergence of a new acute care surgery (ACS) specialty. This study examined the opinions of current general surgical residents about training and careers in this new field. A 36-item online anonymous survey regarding ACS was sent to the program directors of 55 randomly selected general surgery (GS) training programs for distribution to their categorical residents. The national sample consisted of 1,515 PGY 1 to 5 trainees. Response rate was 45%. More than 90% of residents had an appropriate understanding of the components of ACS as generally described (trauma, surgical critical care, and emergency GS). Nearly half (46%) of all respondents have considered ACS as a career. Overall, ACS ranked as the second most appealing career ahead of surgical critical care and trauma but behind GS. Most residents believed that ACS offers better or equivalent case complexity (88%), scope of practice (84%), case volume (75%), and level of reimbursement (69%) compared with GS alone. Respondents who answered ACS had a better scope of practice (61% vs. 36%), lifestyle as an attending surgeon (77% vs. 34%), or level of reimbursement (83% vs. 38%) compared with GS were twice as likely (p < 0.0001) to have considered ACS as a career. Overall, 40% of the residents believed that ACS offers a worse lifestyle in comparison with GS. These results suggest that there is notable interest in the emerging specialty of ACS. The level of resident interest in ACS as a fellowship and career may be increased by marketing those aspects of practice, which are viewed positively and addressing negative perceptions related to lifestyle. It may be appealing to add an elective GS component to certain ACS practice options.