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Predictors of outcomes in emergency general surgery patients : a scoping review Al Hinai, Alreem 2015

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PREDICTORS OF OUTCOMES IN EMERGENCY GENERAL SURGERY: A SCOPING REVIEW  by  Alreem Al Hinai  M.D., Sultan Qaboos University, 2012    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE  in  The Faculty of Graduate and Postdoctoral Studies  (Surgery)    THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2015   ©Alreem Al Hinai, 2015 ii Abstract  Background: Emergency General Surgery (EGS) patients have unique physiologic characteristics and are at a high risk of complications compared to elective general surgery patients. We aimed to perform a scoping review of the literature that examines predictors of outcomes in EGS patients.  Methodology: A scoping review of published literature from 2004 to May 2015 was conducted in Medline, EMBASE, Cochrane library and PubMed. Keywords were chosen based on the three most common diagnoses in EGS; acute appendicitis, cholecystitis and small bowel obstruction, in addition to emergency general surgery, acute care surgery, outcomes & post-operative complications. Articles meeting inclusion criteria were summarized. Quantitative data regarding study characteristics were analyzed and expressed as descriptive statistics.  Qualitative data from included studies were grouped intro predictors based on a framework derived from a grounded theory approach to content analysis. Primary outcomes of interest were post-operative morbidity and mortality. A predictor was included if it was significantly correlated with an outcome based on a minimum of bivariate analysis.  Results: A total of 715 articles were identified during the primary search, of those 62 were found to be relevant to the search criteria. Almost all of the studies were retrospective. The median number of patients in these studies was 1000 (IQR 266,20896) with a mean of median/mean age reported of 53.2 years. Average length of follow up was 4.6 years. There were 54 predictors of outcome identified and these were grouped into patient related, process related and structure/system related predictors. The most frequently reported predictor of any adverse outcome was absence of an EGS system, followed by an ASA score of 3 or more. The most frequently reported predictor of post-operative morbidity was absence of EGS system. The most frequently reported predictor of mortality was age ≥ 65, emergency status and ASA ≥ 3. Conclusion: EGS patients are at a higher risk of post-operative adverse outcome as compared to elective surgical patients. System implementation significantly improves outcomes in this patient population. Identifying what predicts adverse outcomes can help in future risk assessment scores, planning future prospective trials and improving performance in emergency general surgery systems.  iii  Preface  The idea of this research study and its design was established by myself as a first author (AK), Dr Morad Hameed who is my thesis supervisor and Dr Derek Roberts. Key word searches and study selection criteria were established by Dr Hameed and myself with the help of Mr Dean Guistini. Searching the databases and obtaining initial titles and abstracts was performed by myself. The initial phase of selecting the title-relevant articles was performed by Dr. Naisan Garraway (NG) and myself. The second phase of full text review and further exclusion of articles was performed by myself. Data extraction, data and entry and data analysis was performed by myself. Writing the manuscript was done by Dr. Morad Hameed and myself. Parts of this thesis were presented at the Trauma Association of Canada conference in Calgary, April 2015 and published in the Canadian Journal of Surgery.   iv  Table of Contents Abstract ...................................................................................................................... ii Preface ...................................................................................................................... iii Table of Contents ....................................................................................................... iv List of Tables .............................................................................................................. vi List of Figures ............................................................................................................ vii List of Abbreviations ................................................................................................ viii Acknowledgements ................................................................................................... ix Dedication .................................................................................................................. x Chapter 1 Introduction ........................................................................................... 1 1.1 The concept of emergency general surgery ................................................................1 1.2 The emergence of trauma systems and implications on the future of emergency general surgery ..................................................................................................................3 1.3 Defining quality in health care...................................................................................4 1.4 Assessing quality of surgical care ...............................................................................5 1.5 Opportunities for action ...........................................................................................6 1.6 Aim ..........................................................................................................................7 Chapter 2 Methods ................................................................................................. 9 2.1 Definition and Aims of Scoping Reviews .................................................................. 10 2.2 Identifying the research question ............................................................................ 13 2.3 Identifying relevant studies ..................................................................................... 13 2.3.1 Exclusion of gray literature in our methodology ..................................................... 13 2.4 Study selection ....................................................................................................... 14 2.5 Charting data .......................................................................................................... 16 2.5.1 Data extraction ......................................................................................................... 16 2.5.2 Grounded Theory approach ..................................................................................... 17 2.5.3 Content analysis ....................................................................................................... 17 2.6 Summarizing and reporting results .......................................................................... 18 2.7 Statistical analysis ................................................................................................... 19 Chapter 3 Results ................................................................................................. 20 3.1 Descriptive statistics ............................................................................................... 21 3.1.1 Results of study selection process ........................................................................... 21 3.1.2 Characteristics of included studies .......................................................................... 22 3.2 Results of content analysis ...................................................................................... 25 3.2.1 Emerging framework of predictors .......................................................................... 25 3.2.2 Patient related predictors of unfavorable outcomes .............................................. 27 3.2.3 Process related predictors of unfavorable outcomes .............................................. 29 3.2.4 Structure/system related predictors of unfavorable outcomes .............................. 31  v 3.2.5 Most significant predictors associated with post-operative mortality and morbidity 33 Chapter 4 Discussion ............................................................................................ 35 4.1 Predictors of outcome: A foundation for system performance in emergency general surgery ............................................................................................................................ 36 4.2 Status of the literature on predictors of outcome in EGS .......................................... 37 4.2.1 Framework ............................................................................................................... 37 4.2.2 Literature gaps ......................................................................................................... 37 4.2.3 Emerging themes ..................................................................................................... 38 4.2.4 Limitations ................................................................................................................ 39 4.2.5 Future directions ...................................................................................................... 41 Chapter 5 Conclusion ............................................................................................ 44 Bibliography ............................................................................................................. 46 Appendix: Article Summaries .................................................................................... 53      vi List of Tables  Table 1-1 January 2015 Vancouver General Hospital NSQIP semiannual report, decreasing odds ratios of morbidity and mortality in three time periods ................................................................. 7 Table 2-1 Framework for conducting the scoping review ............................................................. 12 Table 3-1 Predictors of all adverse outcomes in order of frequency in included articles ............. 25 Table 3-2 Patient related predictors of unfavorable outcomes in emergency general surgery patients .......................................................................................................................................... 28 Table 3-3 Process related predictors of unfavorable outcomes in emergency general surgery patients .......................................................................................................................................... 30 Table 3-4 Structure/system related predictors of unfavorable outcomes in emergency general surgery patients ............................................................................................................................. 32 Table 3-5 Predictors most frequently associated with primary post-operative outcomes in included articles ............................................................................................................................ 34 Table 4-1 Possible systematic reviews based on the results of our scoping review ..................... 42           vii List of Figures  Figure 3-1 Flowchart of article inclusion process .......................................................................... 22 Figure 3-2 Distribution of included studies separated by study design ........................................ 23 Figure 3-3 Use of ACS NSQIP data in included studies .................................................................. 24 Figure 3-4 Distribution of studies according to type of statistical analysis ................................... 24 Figure 3-5 Basic framework of predictors of unfavorable outcomes in emergency general surgery patientts ........................................................................................................................................ 26  viii List of Abbreviations ACS NSQIP American college of surgeons national surgical quality improvement EGS Emergency general surgery ICU Intensive care unit PIPS Performance improvement and patient safety TGEN Total general TCOLON Total colorectal ACS Acute care surgery OR Operating room ASA American society of anesthesiologists ASA PSA American society of anesthesiologists physical status system SAS Surgical apgar score DSS Disease severity score DNR Do not resuscitate CACI Charlson age adjusted comorbidity index CT Computed tomography US Ultrasound   ix  Acknowledgements   I sincerely thank my supervisor, Dr Morad Hameed for his continuous support and guidance, not only on this project, but also for always providing the best advice and guidance any aspiring future surgeon could hope for.   I would also like to thank Dr Garth Warnock, and Dr Alice Mui for accepting to be part of my masters defense committee.   I would like to sincerely thank Dr Hani Al Qadhi for supporting me and guiding this academic endeavor.       x Dedication   To my mom, my greatest supporter, my role model, my best friend and my inspiration.   My dad, always being proud of me (and bragging about me) no matter how big or little I achieve.   My grandmothers, Aisha who always flooded me with heartfelt prayers, and Sheikha whom I know sends me her prayers, even though her disease stands between her and us.  My sister, the best sister I could ever ask for and the best new mom out there.  My brother, the best brother, whom I am sure is also the best dad-to-be.   My nephew, Haitham, the little boy who occupies an enormous territory in my heart.   To Safiya, always my partner in crime. And they are so many.   My best friends, Rihab and Fatma; this journey would never be as great as it is without your love and laughter.  And all the other beautiful people around me who were, in one way or another, a central part of this journey.  1  Chapter 1 Introduction 1   1.1 The concept of emergency general surgery   The need for modern health care systems to provide excellent, evidence-based and comprehensive care is increasing as patients present with more complex illnesses, often with multisystem involvement. This need is especially evident in emergency general surgical conditions that comprise a very large scope of the overall general surgical practice, that often affect vulnerable patients, and that can lead to severe acute and long-term morbidity, and even mortality. Prompt, comprehensive, multidisciplinary care has the potential to limit the impact of emergency surgical conditions, to restore quality of life, and to prevent mortality.   Around the world and certainly in North America, there is an ongoing trend towards creating systems of emergency general surgery (EGS), that prioritize the care of patients with acute and emergent surgical conditions.  Prior to establishing EGS services, this patient population was managed within a traditional model of health care delivery in which emergency care was accommodated alongside pre-scheduled elective duties of the on-call surgeon.  This model of care clearly has its limitations in terms of providing the best care for a patient population that is probably the sickest amongst all general surgery patients. The organization of care of emergency general surgery patients is a relatively recent phenomenon within general surgical practice. Emergency general  2 surgery has been gaining increasing prominence since around 2003, as surgeons began to realize the unique challenges that define surgical emergencies (1,2).The goal of the emerging EGS systems could be defined as “the urgent assessment and treatment of non-trauma general surgical emergencies in adults” (1,3). It is also noted that due to the emergence of these systems, there has been a very evident transition from the traditional individual responsibility model of provision of care towards the collective model, whereby the delivery of complex and multidisciplinary care becomes a team’s responsibility rather than the responsibility of a single care provider.  The case mix of this patient population in EGS is vast and includes conditions that could probably be classified according to anatomic location and physiologic criteria into acute, non-traumatic conditions related to the upper gastro-intestinal system (e.g. peptic ulcer bleeding/perforation), small bowel (e.g. obstruction), large bowel (e.g. diverticulitis), appendix (e.g. acute appendicitis), biliary tract (e.g. acute cholecystitis), pancreas (e.g. biliary pancreatitis) and certain conditions related to the skin and subcutaneous tissues (e.g. necrotizing fasciitis) (1,4). This is not an exhaustive list as one of the many challenges of the still evolving EGS system is to define the case spectrum that could potentially be treated by the service. The EGS patient population is believed to be unique in terms of the acute physiology, the almost inevitable presence of comorbidities and the high rate of complications (5,6). There is a tendency to believe that complications arising in this patient population is an inevitable course of their illness, but statistics show that these occurrences can be preventable(5).  3  To our knowledge, despite the abundance of literature examining predictors of adverse outcomes in EGS patients, an organized effort has not been made to study those in a systematic framework. Determining these predictors in this patient population can help practicing surgeons working in an EGS service to better understand the dynamics of this patient population and be able to provide care that is as adequate and as structured as that for the elective surgical patient.  1.2 The emergence of trauma systems and implications on the future of emergency general surgery   Historically, trauma surgeons faced a situation that resonates with the challenges in managing EGS patients. The trauma patient population is complex and unique compared with other patients within the scope of general surgery. Their acute physiologic state as a consequence of injury sets them at a very high risk of morbidity and mortality. Trauma surgeons recognized that in order to provide adequate care to this patient population there needs to be a system guided and continuously supported by current evidence and create somewhat of an order within the “complexity” (2,7). This realization resulted eventually in establishing “trauma systems” which are defined as “an organized approach to patients who are acutely injured”(8). This approach towards improving delivery of care has resulted in a major shift in outcomes of trauma patients as evident by a large body or literature(7). An example is a study published in the New England Journal of medicine by MacKenzie et. al. that has shown a significant reduction in in-hospital mortality in patients treated at specialized trauma centers as compared to  4 those who weren’t. This effect was most remarkable in patients who were more severely injured(9).  Lessons learned from the development of trauma systems have been successfully applied in other complex, acute and time-dependent disciplines including burns, critical care medicine and cardiology, and may also be applicable to the care of the EGS patient population that is more or less extremely similar to trauma patients(4). Specifically, the unrelenting focus on performance metrics, outcomes measurement, and system organization that has worked in trauma care, has the potential to shape the evolution of EGS.  1.3 Defining quality in health care   The evolving field of EGS is indeed a great opportunity to establish frameworks for continuous performance improvement and patient safety. Delivering quality health care is probably one of the most challenging tasks in healthcare, one of the reasons being the challenging task of having a universal definition of its essence. In Donabedian’s paper on Evaluating Quality of Health Care(10), he refers to the eight “articles of faith” proposed by Lee and Jones(11) as being probably the best available definition of quality. Reflecting on the aforementioned concepts, it is noted that quality of health care is probably dependent on what experts want it to be(10,12). Achieving the goal of delivering quality in health care ultimately depends on whom it is pertaining to;  5 patients, society, health care workers and policy makers(12). As long as we do not speak the same language when discussing quality of health care, attaining it would remain to be very challenging.   1.4 Assessing quality of surgical care      Assessing quality of health care can be a challenging task(13), as there is a significant amount of interplay between many factors that can affect the delivery of an effective and sustainable heath care system. The Donabedian framework suggests evaluating quality of health care within the realms of three main factors; structure, process and outcome(10). Evaluating the structure pertains to administrative elements such as adequacy of systems and availability of equipment. On the other hand, evaluating the process is related to the patient-health care system interaction, attempting to answer the following question; are we practicing good medicine?(10).   Assessment of outcomes is probably the gold standard method to assess quality of health care delivery, especially in surgical care and probably even more importantly in emergency general surgery. Despite the drawbacks of relying on outcome as a measure of quality assessment (10), it is still a direct way to measure performance in health care, especially in emergency general surgery. Hence comes the importance of examining the available literature on what predicts adverse outcomes in EGS patients and perhaps reflect back on both structure and process measures and their interaction with  6 outcomes as well.  That said, despite the presence of many voices that call for an organized, sustainable approach to delivering quality health care, a consensus is yet to be reached(12). This applies to surgical care. In fact, evidence shows that to this day, a consensus to quality assessment in surgical care ceases to exist. (12). Emergency general surgery systems are especially in need for a consensus that provides a structured basis of assessing quality in health care delivery given the aforementioned high prevalence of complications.   1.5  Opportunities for action  Although the EGS system at Vancouver General Hospital, which was established in 2007, is probably one of the first in Canada, almost no work has been done to assess any aspect of its performance (structure, process or outcome). However, what preliminary work has been done has shown that our patient population is large, diverse in terms of demographics and case mix, affected by multiple comorbidities, and prone to numerous complications. A recent audit of complications in EGS patients that was published by our research group and has shown that almost two thirds of all patients admitted under the service had at least one co-morbid condition(6). The same study also shows that post-operative complications are alarmingly high (25%). This audit is unique in terms of examining complication rates not only in operative patients, but also in non-operative EGS patients that constitute a significant proportion of patients in the service. Some of our work has revealed the promise of greater organization and standardization of care.  7 For example, when the specific diagnosis on biliary pancreatitis was studied, we found that early laparoscopic cholecystectomy for patients with acute mild biliary pancreatitis is associated with a lower rate of biliary complications as compared to standard timing(14). At a more systems based level, analyses of our National Surgical Quality Improvement Program database revealed trends in morbidity and mortality reductions, as processes on the EGS service have been refined (15).  The heavy burden, acuity and complexity of EGS conditions, and the early promise that systems of care may improve outcomes, make a systematic characterization of performance metrics in EGS both timely and essential to the ongoing development in this dynamic area of surgical care delivery.   Table 1-1 January 2015 Vancouver General Hospital NSQIP semiannual report, decreasing odds ratios of morbidity and mortality in three time periods  1.6 Aim   The aim of this study is to analyze the available evidence, to delineate the predictors of unfavorable outcomes in emergency surgical patients admitted to an emergency general surgery service, and determine the most significant factors attributable to post-operative mortality and morbidity. We also aim to formulate an agenda for future  8 clinical trials, systematic reviews and risk assessment scores to predict adverse outcomes in this patient population.      9  Chapter 2 Methods 10   2.1 Definition and Aims of Scoping Reviews   Since our research question covers a very large base of current knowledge and possibly does not fall into a very well defined, structured theme in relation to predictors of poor outcomes in EGS patients, our group decided to adopt the scoping methodology to summarize the available literature (16-19). A scoping review is an approach to review and map the available literature on a subject that is vast or is under-reviewed(16-18). It differs from a systematic review in the precision of the research question, the breadth of literature included for mapping, the general purpose of performing the study and performance of quality assessment in included studies(16). It is said that scoping reviews are more concerned with the “breadth” of literature included but not as much with the “depth” or quality of individual studies(16,17). The general aims of performing a scoping review are as follows:   Determine the characteristics of an ongoing research activity within a specific field.  Summarize and map research findings.  Formulate a framework for performing systematic reviews.  Determine the gaps in the available literature(16,17).  Our approach to the scoping review method has been adopted from Levac et. al. who  11 described a modified approach to the methodology based on Arksey et. al. description of the methodology(16,17).  Table 1 describes the basic framework that we adopted for our methodology. It is noted that we have only included original research articles in our literature search and excluded gray literature for reasons mentioned below. We also omitted the optional expert panel opinion step due to time constraints.   12   Table 2-1 Framework for conducting the scoping review Stage  Description Modifications 1. Identifying the study question What are the predictors of unfavorable outcomes in patients admitted to an emergency general surgery service?   2. Identifying relevant studies Search done in Medline, EMBASE, Cochrane Controlled Trials register and PubMed, pre-specified keywords, English language, 2004-May 2015 Exclusion of gray literature 3.  Study selection Phase 1: title screening Phase 2: title and abstract screening (2 reviewers) Phase 3: full text review (1 reviewer)  4. Charting data Phase 1: designing data extraction form Phase 2: testing the data extraction form Phase 3: data collection 5. Collating, summarizing and reporting results Phase 1: Content analysis  Phase 2: Coding  Phase 3: Data entry  Phase 4: Statistical analysis   Table adopted from Arksey et al and Levac et al(16,17).  13  2.2 Identifying the research question   Our research question was “what are the predictors of unfavorable outcomes in patients admitted to an emergency general surgery service?.” Identifying these predictors will facilitate further understanding of risk assessment measures in EGS patients, as well as map the gaps in the available literature. This will also serve as a basis for future prospective outcome research in the emerging field of emergency general surgery.  2.3 Identifying relevant studies   We have performed a scoping review of the available literature on the following databases: Medline, EMBASE, Cochrane Controlled Trials register and PubMed. The keywords that were agreed upon in our research group where the following:  Emergency General surgery, Acute Care Surgery, treatment outcome, post operative complications, appendicitis, cholecystitis, small bowel obstruction and mesenteric ischemia. The search was limited to literature published in English from 2004 to May 2015.   2.3.1 Exclusion of gray literature in our methodology   The research group has decided not to include gray literature in our search since it has  14 been proven in previous scoping reviews(20) that it did not add much to the knowledge obtained from original research studies. Also, time was a limiting factor to conduct a full review of the gray literature.   2.4 Study selection    The study selection process was undertaken in three phases. Initially, all articles were screened and excluded based on relevance of the title to the research question (phase 1). In screening phase 2, the selected studies were reviewed based on their title and abstracts.  Two reviewers (AK, NG) independently reviewed the articles and further decided on which articles to be included for the secondary review. The agreeability between the two reviewers was very good (kappa statistic= 0.83). Any disagreements between the reviewers were discussed and in case a final decision could not be made, the article was retained for further review.    A set of inclusion criteria were developed and agreed upon by the group to be used in the secondary filtering process to decide on which articles to be included in the final review.   The inclusion criteria were as follows: • Patient population: Adult patients admitted to an Emergency General Surgery service.  15 • Title and abstract key words to be included: Acute Care Surgery (ACS), Emergency General Surgery (EGS). If it was not clear from the title or the abstract that the included patients were not within an EGS service, the full text was searched. • Research Methods: Meta-analyses, retrospective studies, prospective studies, randomized controlled trials. • Predictors to be included: system related (e.g. system implication), provider/process related (e.g. level of training, surgical technique), patient related (e.g. patient demographic data, co-morbidities, functional status) and disease related (e.g. type of disease, anatomic location or disease severity). The list is not exhaustive, and any predictors not categorized within those four themes will be incorporated within the mapping process accordingly.  • Outcomes: The primary outcomes of interest were mortality (in-hospital or 30-day mortality) and post-operative morbidity. Secondary outcomes were time related measures (e.g. time to be seen by a surgeon, time to OR), in-hospital length of stay and readmission rate. This list of outcomes is not exhaustive and will be modified/expanded depending on the findings from the included literature.  Based on the aforementioned inclusion criteria and a full text review of the included articles, one investigator (AK) further decided on which articles to exclude. All the bibliographies of included articles were reviewed by the primary investigator (AK) to  16 minimize the risk of missing articles.   This process is summarized in the form of a flow chart in the results section.  2.5 Charting data  2.5.1 Data extraction   A data extraction sheet was designed to summarize the literature included in the review and it consisted of the following items:  Title  Primary author  Year of Publication  Research question  Study design  Use of ACS NSQIP data  Type of statistical analysis (univariate, bivariate and use of regression models)  Number of patients  Outcome measures  Main outcomes  Length of follow up  Interpretation of results (including results that were statistically significant based on either univariate, bivariate or regression analysis between the examined predictor and the outcome).  17  The initial data sheet was tested by extracting data from 10 different articles and re-examined by two investigators. After co-approval of the data extraction from the group decided to use the form for all the articles included within the review.   2.5.2 Grounded Theory approach   Grounded theory is a sociological approach to data that has been proposed by Strauss and Glaser in the 1960s(21). It has been first developed within nursing research and also became widely used in psychology and education(22). This approach is in its essence is an eccentric take on research methodology in that it promotes permitting data to direct theory construction rather than the traditional scientific approach where a theory is formulated and then data is tested. This approach can be utilized to analyze both qualitative and quantitative data(23). Our study has taken into account grounded theory as an approach to perform content analysis in included literature.   2.5.3 Content analysis   Content analysis is a research tool used to analyze text data derived from various sources, and group them into themes and codes. This allows qualitative text data to be converted into a quantitative form (themes and codes) that enables researchers to summarize it in the numeric form(24,25). This method is originally used in social sciences and has only recently been widely used in health research, specifically in  18 nursing care research(24,25). In an article by Hsieh et al, three different approaches to qualitative content analysis were described; conventional, directed and summative content analysis(25). The conventional approach allows the researcher to explore raw text data and formulate codes and themes guided by it, while the directed approach is a process of exploring text data based on a pre-existing theme or framework obtained from previous knowledge in the field. The summative approach is in its essence a combination of both approaches. Given the diversity of our text data, we have decided to adopt the summative approach to content analysis. Using a combination of grounded theory approach and summative content analysis, we have attempted to map emerging themes of the predictors of unfavorable outcomes in the EGS patient population.  That process consisted of analyzing all the summaries of included articles that specify a certain predictor to be statistically significant based on univariate, bivariate or regression analysis. Emerging predictors were coded accordingly. These were collapsed into groups of themes. The total number of codes and frequency of each was calculated.   2.6 Summarizing and reporting results   The included articles were summarized in the form of a flow chart to visually represent the process of study selection and inclusion. A description of all included articles and baseline patient characteristics was presented in a table by means of basic descriptive statistics. Results of the Newcastle-Ottawa Score and results of content analysis were  19 expressed using descriptive statistics and relevant charts.  2.7 Statistical analysis Data entry and analysis were performed in Microsoft Excel 2011 and R© version 0.98.1091. Results were expressed in terms of descriptive statistics and appropriate representative charts.   20  Chapter 3 Results 21   3.1 Descriptive statistics   3.1.1 Results of study selection process   Our search initially yielded 715 articles in all databases; all were screened based on the title. Five hundred and thirty eight articles were excluded after initial phase screening. Subsequently, two reviewers screened 177 articles based on the title and abstract and further decided on which articles to include. The inter-observer agreeability was very good (kappa statistic= 0.83). The primary investigator reviewed the full texts of included. Based on the inclusion criteria mentioned in our methods section, the primary investigator further excluded 40 articles. All the bibliographies were reviewed and 8 additional papers were identified and included in the analysis. The flowchart in Figure 3-1 visually represents the above-mentioned findings.    22  Figure 3-1 Flowchart of article inclusion process  3.1.2 Characteristics of included studies   The median number of patients included was 1000 patients (Inter-quartile range 266,20896). The minimum number of patients included was 44 and the maximum number was 17,985,559 patients. The mean of mean/median age reported in the included studies was 53.2 years. It is noted that 8 out of the 62 studies did not report the mean or median age of included patients. The mean of percent males reported was  23 48.36%. The average follow up time was 4.6 years. Almost all of the included studies were retrospective studies, with over one third being retrospective cohort studies as represented in Figure 3-2. The remaining retrospective analyses were either retrospective before and after studies or case control studies. There was one metanalysis of 18 retrospective studies. Twenty seven percent of all studies used data from the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) as shown in Figure 3-3. About 53% of all included studies undertook regression modeling to adjust for confounding variables of outcome predictors (Figure 3-4).  Figure 3-2 Distribution of included studies separated by study design  16242110 5 10 15 20 25 30Retrospective case-control studiesRetrospective cohort studiesRetrospective before and after studiesmetanalysisNumber of studiesStudy design 24  Figure 3-3 Use of ACS NSQIP data in included studies     Figure 3-4 Distribution of studies according to type of statistical analysis17, 27%45, 73%YesNo1273310 5 10 15 20 25 30 35UnivariateBivariateRegression modelingmetanalysisNumber of studies includedType of statistical analysis 25  3.2 Results of content analysis 3.2.1 Emerging framework of predictors    Our summative content analysis revealed a framework that is derived both from the Donabedian framework(10), as well as one derived from Vincent and colleagues’ work on analyzing adverse events in health care(26). The basic framework consisted of three main stems; patient related predictors, process related predictors and structure/system related predictors (Figure 3-1). Within each main stem, the analysis revealed several subcategories grouping the emerging predictors as seen in Figure 3-5. The total number of predictors identified that were significantly correlated with any adverse outcome on a minimum of bivariate analysis, was 54 predictors. Thirty-five of those were patient related, eleven were related to the process of health care delivery and the remainder were related to health care structure/system. Table 3-1 lists the most frequently encountered predictors that were significantly correlated with any adverse outcome within all three main stem categories. Table 3-1 Predictors of all adverse outcomes in order of frequency in included articles Predictor/Predictors Frequency Absence of EGS system 18* ASA ≥ 3 6 Emergency status 5 Age ≥ 65 5 Pre-operative systemic inflammation/sepsis 3 Pre-operative functional status 2 Smoking 2 Creatinine 2 Post-operative complications 2 *A predictor is accounted for based on a statistically significant correlation with any unfavorable outcome on bivariate or multiple regression analysis. ASA, American Society of Anesthesiologists; EGS, Emergency General Surgery.  26  Figure 3-5 Basic framework of predictors of unfavorable outcomes in emergency general surgery patientsPredictors of unfavorable outcomes in EGS patientsPatient related predictorsDemographicsBiometricsHemodynamic valuesComorbiditiesPre-operative assessmentPre-operative interventions/medicationsIntra-operative findingsInvestigationsProcess related predictorsEmergency case statusOperative techniquePost-operative complicationsUtilization of radiological investigationsTime related measuresTrainee participationSystem related predictorsImplication of an EGS systemHospital teaching statusTrauma center statusDistance from regional EGS centerHospital structureSafety net hospital 27  3.2.2 Patient related predictors of unfavorable outcomes   The first and probably the most extensive main stem category revealed by the analysis are patient related predictors of unfavorable outcomes. There were a total of 36 predictors within this category. The predictor that was most frequently associated with an adverse outcome in EGS patients within this category was an ASA score of more than 3, which was found to be significantly correlated with adverse events in 6 different studies(27-32). Following ASA, elderly patients (age ≥ 65) were frequently found to have worst outcomes as compared to younger patients(29,31-34). Pre-operative systemic inflammation or sepsis has also been identified as a significant predictor of adverse events in three different articles(27,30,35). Other factors such as smoking(31,32) and pre-operative functional status(30,31) were significant predictors in two articles each. The other factors listed in Table 3-2 were found to be significantly associated with an adverse outcome in one study each.   28 Table 3-2 Patient related predictors of unfavorable outcomes in emergency general surgery patients Patient related predictors Demographics Age Elderly, age ≥ 65 (5)* Gender  Male (1) Race African American (1) Insurance level Uninsured (1) Level of income Low income (1) Biometrics BMI ≥ 29 (1) Hemodynamic values Blood pressure Low blood pressure (1) Core body temperature Hypothermia (1) Respiratory assessment Dyspnea at rest (1) Pulse rate Tachycardia (1) Comorbidities Substance abuse Smoking (2) Alcohol Abuse (1) Systemic Disease COPD (1) PVD (1) Hepatic Disease (1) Acute renal failure (1) Pre-operative assessment Code status DNR status (1) Clinical physiologic assessment Pre-operative systemic inflammation/sepsis (3) Pre-operative functional status (2) Respiratory failure (1) Shock (1) Risk assessment scores ASA ≥ 3 (6) SAS (1) CACI (1)  ASA PSA (1) Pre-operative interventions/medications Pre-operative blood transfusion (1) Pre-operative use of anticoagulants (1) Intra-operative findings Ischaemic bowel (1) DSS for acute appendicitis (1) Investigations Laboratory findings Elevated blood glucose (1) Elevated creatinine levels (1) Leukopenia (1) Leukocytosis (1) Increased BUN (1) Radiologic findings Sarcopenia (1) *Italic phrases indicate predictors. Numbers between two brackets indicate the frequency of the phrase as a significant predictor on a minimum of bivariate analysis.  BMI, Body Mass Index; COPD, Chronic Obstructive Pulmonary Disease; PVD, Peripheral Vascular Disease; DNR, Do Not Resuscitate; ASA, American Society of Anesthesiologists; SAS, Surgical Apgar Score; CACI, Charlson Age-adjusted Comorbidity Index; ASA PSA, American Society of Anesthesiologists Physical Status System score.  29  3.2.3 Process related predictors of unfavorable outcomes   Within the main stem of predictors related to the process of care, we found a total of 11 predictors that were significantly correlated with adverse outcomes in emergency general surgery patients. The most frequent one being emergency status, which means being an EGS patient as compared to an elective surgical patient has been found to be significantly associated with an adverse outcome(27,28,36-38). Four out of these five studies used regression models to adjust for confounders of emergency status in relation to adverse outcomes(27,28,36,37). We also note the presence of post-operative complications significantly correlate with adverse outcome specifically with post-operative mortality(39) and increased length of stay(32). Other predictors within this category were significant in one study each as listed in Table 3-3.  30 Table 3-3 Process related predictors of unfavorable outcomes in emergency general surgery patients Process related predictors Emergency case status (as compared to elective) Emergency status (5)* Operative technique Procedure performed Anastomosis technique Stapled anastomosis (As compared to hand-sewn) (1) Status of procedure Emergency status (1)  Disease  Small bowel obstruction Open surgery (as compared to laparoscopic) (1) Small bowel resection (as compared to no bowel resection) (1) Colorectal resection APR (1) Post-operative complications Presence of post-operative complications (2) Utilization of radiological investigations Underutilization of radiologic investigations Non-use of CT scan (1) Use of US (1) Time related measures Operating room latency Latency ≥ 60 hours (1) Length of surgery Length of surgery ≥ 120 minutes (1) Trainee participation Presence of trainee (1) *Italic phrases indicate predictors. Numbers between two brackets indicate the frequency of the phrase as a significant predictor on a minimum of bivariate analysis.  APR, Abdomino-perineal resection; CT scan, Computed Tomography scan; US, Ultrasound.   31  3.2.4 Structure/system related predictors of unfavorable outcomes   The last main stem category finding in our analysis was structure/system related predictors. Although this category revealed the least total number of predictors or codes of adverse outcomes, absence of EGS system was found to be the most frequently studied predictor amongst all included studies. The aforementioned predictor was found to be significant in 18 different articles comparing outcomes in traditional on-call models (explained in section 1.1) to EGS models(40-57). In these articles, primary and secondary outcomes were examined in three main diseases; acute appendicitis, biliary disease and colorectal disease. One of these studies demonstrated a significant effect of implementation of an EGS model on time related outcomes (surgical decision time) and overcrowding in the emergency department(55). There was a discrepancy within outcomes related to trauma center status and its correlation with outcomes in EGS patients. On one hand, a study showed that trauma service coverage improved the management of patients admitted with acute appendicitis(58), while in two other studies trauma center status was correlated with overall morbidity(59) in patients with extreme All Patients Refined Severity of Illness score (APR-SOI)(60). Table 3-4 all the predictors within this category. 32 Table 3-4 Structure/system related predictors of unfavorable outcomes in emergency general surgery patients Structure/system related predictors Implication of an EGS system  Absence of EGS system (18)  Hospital teaching status Non-teaching hospital (1) Trauma center status Presence of trauma center (2) Absence of trauma service coverage in appendectomies (1) Distance from regional EGS center Longer distance from regional EGS center (1) Hospital structure Number of ICU beds (1) Safety net hospital  Being a safety net hospital (1) *Italic phrases indicate predictors. Numbers between two brackets indicate the frequency of the phrase as a significant predictor on a minimum of bivariate analysis.  EGS, Emergency General Surgery; ICU, Intensive Care Unit.  33  3.2.5 Most significant predictors associated with post-operative mortality and morbidity   The analysis of how different predictors relate to our primary outcomes of interest revealed that for post-operative mortality, the most frequently associated predictors were Age ≥ 65(29,31,33,34), emergency status(27,36-38) and ASA ≥ 3(27,29,31)(Table 3-5). Pre-operative systemic inflammation or sepsis was also significantly correlated with postoperative mortality in 3 different studies(27,30,35). In the study by Becher et al(35), probability for mortality increased as the degree of inflammation/sepsis increased.  As for post-operative morbidity, absence of an EGS system(41-44,46,53) was the most frequently encountered predictor followed by pre-operative functional status(30,31) and smoking(31,32).  Secondary outcomes that were identified in the included literature were time related measures (e.g. time to surgical consultation, time to surgical decision making, time to OR, etc.) (44,47,50,53,61), re-laparotomy rates(62), ICU admissions(32), readmission rate(28) and length of stay(44,61,63).       34 Table 3-5 Predictors most frequently associated with primary post-operative outcomes in included articles Predictors of in-hospital or 30-day mortality Frequency Age ≥ 65 4* Emergency status 4 ASA ≥ 3 4 Pre-operative systemic inflammation/sepsis 3 Pre-operative functional status 2 Smoking 2 Post-operative complications 2 Predictors of post-operative morbidity  Absence of EGS system 6 Pre-operative functional status,  2 Smoking 2 *A predictor is accounted for based on a statistically significant correlation with any unfavorable outcome on a bivariate or multiple regression analysis. ASA, American Society of Anesthesiologists; EGS, Emergency General Surgery.  35  Chapter 4 Discussion 36   4.1 Predictors of outcome: A foundation for system performance in emergency general surgery   The principles and practice of emergency general surgery, which have been built on a strong foundation of scientific knowledge and on decades of hard won experience, have helped to reduce morbidity and mortality on a global scale. Emergency general surgery has always been a core discipline in medicine, and central to the function of acute care health systems. As hospital based care becomes more acute, complex and multidisciplinary, the importance and responsibility of EGS will continue to increase.   New models of emergency general surgery care delivery have the potential to reshape modern healthcare. As we have seen, there is already a rich body of literature suggesting that greater organization of EGS care has the potential to improve the experience of hundreds of thousands of patients. The simultaneous development of EGS services across North America have created an exciting and unprecedented opportunity to establish and generalize frameworks and benchmarks for health care quality and patient safety in this area.  The first steps in establishing frameworks for performance improvement and patient safety in EGS, are to begin to understand the patient populations and case mix, the  37 common interventions used, and the determinants of outcome. This thesis has assembled the literature on the experience of the newly developing EGS services and has attempted to organize the perspectives they have taken to measuring their impact on quality. It has also attempted to assemble current knowledge of determinants of outcome, or risk factors, to begin to set the stage for future work on risk adjustment, that will support global outcomes comparisons and practice standards in EGS. A strong understanding of risk factors will support both health services and front line clinical decision making.  4.2 Status of the literature on predictors of outcome in EGS  4.2.1 Framework    The structure / process / outcome framework, described by Donabedian as an organizational system for health care quality improvement, was used as a starting point in our literature classification process. (10) by Vincent and colleagues(26) (This emerging framework could serve as an outline for future scoring systems for individual patient assessment and risk stratification, health services performance improvement, and clinical research.  4.2.2 Literature gaps   To date, the existing knowledge pertaining to EGS patients remains limited. Even though we have evidence to support the positive outcomes related to system implementation, it is restricted to common and less severe conditions (appendicitis, cholecystitits), and we are in dire need of research studies that examine outcomes of more complex  38 surgical diseases. Not only are we in need of studies examining complex operative diseases, but also of studies of outcomes in the significant proportion of EGS patients who undergo non-operative management. These patients are seldom included in analyses derived from databases such as the ACS NSQIP data.   There are certain risk factors that are potentially correlated with adverse events in this patient population but are also not extensively investigated, such as the role of socio-economic factors in predicting adverse outcomes. For example, our analysis identifiedonly one study that evaluated a social determinant of heath:  in this case, the correlation between race and adverse in outcomes in EGS. This study showed significantly worse outcomes for patients who are African American as compared to Caucasians, even after adjusting for other confounding variables(64). Development of EGS services that account for societal vulnerabilities is a promising opportunity that must be supported by surgical research. 4.2.3 Emerging themes    Three themes emerged from a comprehensive analysis of the literature on determinants of outcome in EGS. First, emergency general surgery patients are at risk for worse outcomes compared with elective surgical patients, even after adjusting for possible confounders(27,28,36-38). This finding is, yet to be fully understood, but is not surprising to health care workers who provide care to patients presenting with emergency surgical conditions. The second theme we observed in the EGS literature is  39 that there are clear risk factors for adverse outcomes in EGS patients. This has been clearly demonstrated in common emergency surgical conditions such as acute appendicitis and biliary disease. These conditions are surely two of the most common, but are by nature less morbid than other surgical diseases that also fall within the spectrum of EGS care, such as bowel perforation and bowel ischaemia.  Future studies of more morbid and complex conditions may eventually define even more disease specific risks or combinations of risks for adverse outcomes. This observation is important because it emphasizes the opportunity for health systems to reduce risks and complications in a population of patients where complications are sometimes considered to be inevitable. For the first time, we are beginning to see that attention to potentially modifiable risks may improve outcomes in a complex and heterogeneous patient population. The third theme emerging from our analysis is that organized EGS service delivery models have the potential to improve patient outcomes(40-57). This finding supports the notion that the phenomenon of organizing care in this population, and, by implication optimizing the structure and process of complex delivery of emergency surgical care, is a modifiable factor that can reduce complications. Even modest reductions in adverse events in the EGS population have the potential to make a big impact on the lives of patients and on the costs of healthcare. 4.2.4 Limitations   There were several limitations encountered in our study. The decision over which framework to base our analysis on has certainly been a challenge since there is no  40 consensus over quality assessment frameworks in surgical care. A modified grounded theory approach to the literature eventually guided us to a structure / process / outcome approach to organizing the literature, with a strong focus on those aspects of structure and process that are known to impact outcome. To focus this framework even more on predictors of patient outcome, and to be more inclusive of the available literature on EGS outcomes, we added provider, technical, socioeconomic and patient risk factors as sub categories under the outcomes category. Another limitation of our study is our decision not to evaluate the grey literature as suggested by the majority of authors outlining the suggested methodology of scoping reviews(16,17). The grey literature could have theoretically added to our knowledge, however we based our decision of not including it on a previous research project where it wasn’t found to add much to the knowledge obtained from original research studies(20). Even though we aimed to be exhaustive in our search methods criteria (e.g. searching all included bibliographies for any missing literature), there is still a chance that we could have missed some research papers in our analysis. Another, perhaps major, limiting factor in our study is the quality of included evidence. Almost all of the included articles (with the exception of one metanalysis of 18 retrospective studies) were retrospective studies, with the majority being retrospective cohort studies. However, it should be noted that more than half of all included articles attempted to account for the lower quality study design by constructing different types of regression models depending on the measured outcome. Even though our study has taken into account the methodology of our included studies when examining predictors, we haven’t performed a formal  41 assessment score for quality of evidence or quality of methodology. This factor will be compensated for in future systematic reviews as will be discussed in section 4.2.5. 4.2.5 Future directions   4.2.5.1 Systematic reviews   As discussed in the previous section, future systematic reviews on more homogeneous research articles within each branch of our framework could help to measure and possibly address some of the limitations in the research methods identified in our scoping review. Analyzing and merging published data and interpretations of data may enable us to make stronger evidence based conclusions derived from the research articles included. In Table 4-1 we propose 3 different possible systematic reviews in three different homogenous groups of research studies: predictors of outcomes in elderly patients admitted to EGS services, a comparison of outcomes in emergency and elective general surgical patients, and predictors of adverse outcomes in EGS patients using the ACS NSQIP database.         42 Table 4-1 Possible systematic reviews based on the results of our scoping review Suggested systematic reviews Possible articles to include Predictors of adverse outcomes in elderly patients admitted to EGS services (34,65-69) A comparison of outcomes in emergency versus elective general surgical patients (27,28,36-38) Predictors of adverse outcomes in EGS patients using the ACS NSQIP database (27-31,34-39,59,68,70-72)  4.2.5.2 Establishing quality improvement databases  As EGS services become more established and more focused on performance improvement and patient safety (PIPS), we anticipate that there will be a strong need for the collection of actionable clinical data. For EGS, PIPS databases will ideally reflect the broad spectrum of surgical patients and surgical conditions, the wide array of operative and non-operative approaches to surgical care, the often complex postoperative issues faced by patients and health care systems, and the long term outcomes of EGS patients. Databases should be able to identify modifiable risk factors and measure the impact of changes in process on outcomes. These databases should also be able to provide data for emerging risk adjustment strategies, as EGS services begin to explore synergies to optimize outcomes across entire populations. It is hoped that groundwork on EGS risk factors done in this thesis will help PIPS experts, researchers and policy makers in EGS to plan data elements for EGS databases, and to make them more relevant to efforts aimed at reducing risks and measuring outcomes.   43 4.2.5.3 Multicenter prospective studies  In order to be able to design higher quality evidence data, we need to plan multicenter prospective studies to achieve the recruitment of a higher numbers of patients and increase the power of studies to measure the effects of new interventions. This is particularly important for the less frequent but highly complex and severe EGS conditions, where PIPS efforts and research have the potential to dramatically reduce complications and health care costs. Our scoping review is a starting point in the planning of multicenter studies because it identifies the current literature, highlights gaps, and summarizes risk factors for adverse outcomes.  44  Chapter 5 Conclusion 45    The creation of dedicated EGS services across North America has opened new opportunities for much needed quality improvement and research. The available literature has begun to characterize what has long been suspected: that emergency surgical conditions are risky and associated with a high proportion of adverse events, that there are defined and potentially modifiable risk factors for adverse outcomes among these patients, and that the organization of service delivery has the potential to change patient outcomes. The EGS literature has generated thoughtful studies and rigorous analyses, and has capitalized on large national datasets, such as NSQIP, to highlight the vastness of the EGS patient cohort and the resulting potential power of EGS systems to make a meaningful impact on modern health care. The emerging literature already has a strong focus on patient outcomes, but must expand its emphasis on the structure and process of EGS systems of care, and must characterize patient vulnerability, diverse case mix, operative and non-operative interventions, and long term outcomes even better.  The opportunities for conducting refined systematic reviews, for the creation of actionable performance improvement and patient safety datasets with a strong emphasis on surgical risk factors, and for the performance of multicenter studies on specific aspects of EGS practice are great, and are unprecedented in the history of emergency general surgery.    46 Bibliography  1. Ball C, Hameed SM, Brenneman FD. 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Surg Endosc. 2014 Mar 21;28(8):2381–6.   53  Appendix: Article Summaries  54 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation An Acute Care Surgery Model Improves Outcomes in Patients With Appendicitis Earley, AS. et. al. 2006 Annals of Surgery To compare the traditional on-call model with the acute care surgery model in terms of outcomes for patients diagnosed with acute appendicitis Retrospective analysis  Traditional model and ACS model Key time intervals, outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay) 1999-2002 -Improved time from ED to OR -Decreased rupture rates -Decreased complication rates  (unadjusted)   Risk Factors for Adverse Outcomes Following Surgery for Small Bowel Obstruction Margenthaler, JA 2006 Annals of Surgery To construct risk indices predicting adverse outcomes following surgery for small bowel obstruction (SBO). Retrospective analysis using NSQIP data 1650 adhesiolysis 352 small bowel resection Pre-surgical and intra-operative factors in two groups, adhesiolysis and small bowel resection Morbidity and mortality 1991-2002 Patients who underwent small bowel resection had a higher rate of having one or more post operative complication. Overall 30-day mortality was not different. Odds of death were highest for dirty or infected wounds, ASA class 4 or 5, age > 80 years, and dyspnea at rest. Management of Acute Appendicitis by an Acute Care Surgery Service: Is Operative Intervention Timely? Ekeh, AP. et. al.  2008 Journal of the American College of Surgeons Compared two periods at a Level I trauma center to determine if trauma service coverage would negatively impact timely management of acute appendicitis. Retrospective analysis 273 in ore-trauma  279 in post-trauma Pre and post trauma period Key time intervals, negative appendectomy rates, perforated appendicitis rates. Trauma period: March 2005 to May 2006 Pre-trauma period: December 2003-February 2005 More appendectomies were completed laparoscopically and mean OR time was shorter.  Other time parameters, perforation rates and negative appendectomy rates were not  55 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation statistically different among the groups. Acute-care surgical service: a change in culture Parasyn, AD. et. al. 2008 ANZ Journal of Surgery The aim of the study was to show an improvement in patient management, hospital management, theatre management and lifestyle of the ACS. Retrospective analysis Not specified Pre and post Acute Care Surgical service establishment Emergency theatre times, theatre utilization, out of hour operating, acute care registrar admissions saved, staff morale, total theatre block utilization 12 weeks, 2005 compared to 12 months prior to the establishment of the system. Emergency theatre utilization during the day increased from 57 to 69%. There was a 11% reduction in acute-care operating after hours and 26% fewer emergency cases were handled between midnight and 08.00 hours. Does an acute care surgical model improve the management and outcome of acute cholecystitis? Lehane, C. et.al. 2009 ANZ Journal of Surgery To compare the management and outcome of acute cholecystitis in an acute care surgery (ACS) model to that of the traditional home-call attending surgeon Retrospective analysis  202 patients Traditional model and ACS model Time from surgical diagnosis to operation, consultant presence in theatre, open conversion rates, post-operative length of stay, complications, histopathology results. Traditional group (1 September 2003–31 August 2005) ACS group (1 September 2005–31 August 2007) There was a decrease in the median time to theatre, total length of stay and complication rate in the ACS group as compared to the traditional group. Impact of Acute Care Surgery on Biliary Disease Britt, RC. et. al 2009 Journal of the American College of Surgeons To examine the impact of ACS system implementation on biliary disease.  Retrospective analysis 54 pre-ACS 132 post-ACS Pre-ACS and post ACS on all operative biliary disease patients  Time from admission to operation, time of operation, length of stay, comorbidities, and complications. One year before implementation and two years after implementation of ACS service, implemented in 2007 Decreased time from admission to OR, shorter length of stay, no difference in complication rates and conversion to open. Initial ImplementatioBritt, RC. et. al. 2009 Journal of the To evaluate the impact on patient Retrospective analysis 861 patients Pre-ACS and post-ACS Day time versus after hour Pre-ACS: 2006 through Daytime surgery increased  56 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation n of an Acute Care Surgery Model: Implications for Timeliness of Care American College of Surgeons care and describe the case-mix experienced. emergency surgery.   March 2008 Post-ACS:  significantly to 70%. Procedures performed after 5:30 PM decreased from 44.6% to 30%. Octogenarian Abdominal Surgical Emergencies: Not So Grim a Problem With the Acute Care Surgery Model? Rubinfeld, I. et. al. 2009 The Journal of Trauma, Injury, Infection and Critical Care To evaluate outcomes of major abdominal surgery in elderly patients (80 years and older). Retrospective analysis  183 operations Pre-operative ASA score, gender, comorbidities. After-hours operations, length of stay, duration of operation, gender, comorbidities, and mortality. 2000-2006 Significant predictors of mortality were ASA class and female gender in this population.  Triaging to a Regional Acute Care Surgery Center: Distance Is Critical Diaz, JJ. et. al. 2010 The Journal of Trauma, Injury, Infection and Critical Care To determine if distance to a referral center and severity of illness (SOI) are predictors of mortality Retrospective analysis 3,439 Age, distance, severity of illness Mortality upon discharge 2004-2008 Age and SOI were significantly associated with mortality  After controlling for age and severity of illness, distance was significantly related to mortality  Appendicitis outcomes are better at resident teaching institutions: a multi-institutional analysis Yaghoubian, A. et. at. 2010 The American Journal of Surgery To compare the outcomes of appendicitis in teaching and non-teaching hospitals Retrospective analysis 3242 patients at teaching institutions, 14,483 at non-teaching institutions, 2 teaching institutions and 11 non-teaching institutions Teaching versus non teaching status Post-operative morbidity and length of stay 1998-2007 Teaching hospitals had lower abscess drainage rate, shorter hospital stay and lower readmission rate as compared to non-teaching hospitals.  Effect Of Trauma Center Status on 30-Day Outcomes Ingraham, AM. et. al. 2010 Journal of the American College of To assess EGS outcomes in trauma versus non-trauma Retrospective analysis using NSQIP data 68,003 patients at 222 hospitals; 42,264 treated at 121 TCs, 25,739 Trauma versus non-trauma center status Overall morbidity, serious morbidity, and mortality. 2005–2008 TCs had significantly higher overall morbidity, serious morbidity,  57 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation After Emergency General Surgery Surgeons centers. (37.8%) were treated at 101 NTC.  and mortality than NTCs on non-adjusted analysis. After adjustment, TC status was significantly associated with overall morbidity but not serious morbidity and mortality.  Outcomes of appendicectomy in an acute care surgery model Gandy, RC. et. al. 2010 Medical Journal of Australia To assess the outcomes of appendicectomy in an acute care surgery (ACS) model compared with a traditional on-call (Trad) model. Retrospective analysis 176: Trad period 226: ACS period. Traditional versus ACS model Complication rates (wound complications, intra-abdominal collections, small bowel obstructions and readmissions, cardiac, respiratory, thromboembolic complications and urinary tract infections). Traditional period: April 2004 to March 2005 ACS period: April 2006 to March 2007 Complication rates were significantly reduced in the ACS model. The acute surgical unit: improving emergency care Conrady, DV. et. al. 2010 ANZ Journal of Surgery To analyze the impact of the ASU on waiting times in the emergency department until surgical consultation. Retrospective analysis Emergency referrals ACS period: 974 Emergency referrals pre ASU 901 Pre and post ASU status Waiting times in the emergency department, operative intervention, time of operation, number of appendectomies performed, weekend discharge rates, length of stay Pre ASU: February-April 2008 Post ASU: February-April 2009 Waiting times were reduced, more procedures were performed during day time, more weekend discharge dates Comparison of Hospital Performance in Emergency Ingraham, A. et. al. 2010 Journal of The American College To compare risk factors and risk adjusted outcomes in EGS Retrospective analysis using ACS-NSQIP 473,619 procedures, 67,445 emergency ACS-NSQIP predetermined measures in elective versus Morbidity and mortality  2005-2008 EGS are at higher risk for serious morbidity as compared to  58 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation Versus Elective General Surgical Operations at 198 Hospitals Of Surgeons patiens as compared to elective to assess whether hospital shave comparable outcomes  database procedures  emergency patients elective patients Hospitals do not appear to have highly consistent performance across both Comparison of Hospital Performance in Nonemergency Versus Emergency Colorectal Operations at 142 Hospitals Ingraham, AM. et. al. 2010 Journal of The American College of Surgeons To assess whether hospitals have comparable outcomes for emergency and nonemergency operations Retrospective analysis using ACS-NSQIP database 5,083 emergency patients 25,710 elective patients ACS-NSQIP predetermined measures in elective versus emergency patients Thirty day mortality and morbidity after emergency and elective colorectal resections 2005-2007 Emergency colorectal resection patients had significantly higher mortality rates, morbidity rates, had more comorbidities, had higher ASA scores. The development of any complication was twice as likely in emergency as compared to non-emergency patients. Complications with the highest unadjusted RR were pulmonary. Preoperative sepsis, creatinine, and transfusion were selected within the first 5 predictors for morbidity and the first 13 predictors for mortality after nonemergency and emergency operations; acute renal failure was also selected  59 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation as a predictor of morbidity. Acute Care Surgery Performed by Sleep Deprived Residents: Are Outcomes Affected? Yaghoubian, A. et. al. 2010 Journal of Surgical Research To compare the outcomes of both laparoscopic cholecystectomy and appendectomy performed by residents during daytime and early evening hours versus those performed during night hours after a 16-h shift Retrospective analysis 2908 laparoscopic cholecystectomies 1726 appendectomies Daytime procedures versus night hour procedures Rates of total complications, bile duct injury, conversion to open operation, length of surgery, and mortality. 2003-2009 No difference in outcomes between the two groups. Acute Care Surgery Program: Mentoring Fellows and Patient Outcomes Diaz, JJ. et. al. 2010 Journal of Surgical Research To assess if EGS patient outcomes (morality and infections) would differ by provider (faculty or fellows) on a service driven by evidence-based medicine (EBM) protocols Retrospective analysis 1769 patients Surgeon (fellow versus staff) Post-operative infections and mortality. 2003-2007 There was no statistical difference in mortality, LOS, ICU LOS, disposition, ventilator d, and IC between faculty and fellow providers. Comparison of 30-day outcomes after emergency general surgery procedures: Potential for targeted improvement. Ingraham,A.M. 2010 Surgery -Comparison of 30 days morbidity/mortality in emergency general surgery patients undergoing appendectomies, cholecystectomies & colon resection within and across participating Retrospective analysis using NSQIP database 30,788 appendectomies, 5,824 cholecystectomies, 8990 cholecystectomies Patient age, sex, race, body mass index (BMI), American Society of Anesthesiologists (ASA) class, and pre- operative functional status (as defined by ACS 30-day overall morbidity and serious morbidity/mortality.  2005-2008   -Colorectal resections carried the highest risk for morbidity/mortality, specifically abdomino-perineal resection  -Most important predictors for unfavorable outcomes are: pre-operative sepsis, ASA  60 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation hospitals -patient related and procedure related risk factors for morbidity/mortailty  NSQIP), surgical procedure, comorbidities, behavioral factors and lab values.  classification and functional status Does Regionalization of Acute Care Surgery Decrease Mortality? Diaz, JJ. et. al. 2011 The journal of Trauma To evaluate whether a mature emergency general surgery care system would decrease morbidity and mortality over time.  Retrospective analysis 3,439 patients Measures of Severity of Illness (SOI) were systemic inflammatory response syndrome, sepsis, shock, peritonitis, perforation, and acute renal failure mortality, LOS, intensive care unit admissions, SOI, charges, and distance 2004-2009 Mortality decreased significantly throughout the years An Acute Care Surgery Model Improves Timeliness of Care and Reduces Hospital Stay for Patients with Acute Cholecystitis Lau, B. et. al. 2011 The American Surgeon To examine the impact of an Acute Care Surgery model on the timeliness of care and length of hospital stay in patients with acute cholecystitis Retrospective analysis 71 patients in ACS group and 81 in Pre-ACS group Pre and post-ACS Length of stay (LOS) and time from the ED to the operating room Pre-ACS (October 2008 to September 2009) Post-ACS (October 2009 to July 2010) ACS group had shorter average time from ED to OR, reduced length of stay, reduced after-hour cases and decreased complication rates. The Impact of an Acute Care Emergency Surgical Service on Timely Surgical Decision-Making and Emergency Department Overcrowding Qureshi, A. et. al. 2011 Journal of The American College of Surgeons To evaluate the impact of ACS establishment on ED key determinants of length of stay (surgical decision time) and overcrowding.  Retrospective analysis  1448 pre-ACCESS 1062 Post-ACCESS Pre and post ACCESS Primary outcome: surgical decision time. Secondary outcomes: time-to-stretcher as a measure of overcrowding. For appendicitis group, key time intervals were Pre-ACCESS: from January 1, 2007 to June 2008 Post-ACCESS: from July 2008 to June 2009 ACCESS implementation was associated with a 15% reduction in surgical decision time, decreased time-to-stretcher. Patients with non-perforated appendicitis on CT  61 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation measured, along with perforation rates and hospital length of stay. scan with a fecalith are more likely to suffer from perforation while waiting for surgery. Variation in Quality of Care after Emergency General Surgery Procedures in the Elderly Ingraham, AM. et. al. 2011 Journal of The American College of Surgeons To compare 30-day outcomes between the elderly and the young following emergency general surgery and determine if hospital performance is consistent across there groups. Retrospective analysis using ACS NSQIP data 68,003 procedures 186 hospitals Young versus elderly patients Serious morbidity and mortality 2005-2008 Elderly patients had a higher crude rate for mortality and serious morbidity as compared to young patients.  When compared across hospitals there was moderate agreement in terms of morbidity but not mortality. A Critical Assessment of Outcomes in Emergency versus Nonemergency General Surgery Using the American College of Surgeons National Surgical Quality Improvement Program Database   Becher, RD. et. al. 2011 The American Surgeon To assess and quantify postoperative morbidity and mortality for emergency versus non-emergency general surgery operations.  Retrospective analysis using ACS-NSQIP database 25,770 emergency cases 98,867 non-emergency cases ACS-NSQIP predetermined measures in elective versus emergency patients -30 days mortality -occurrence of 1 or more post operative complication within 30 days  2008 -As compared to non-emergent operations the relative risk for mortality of an emergent procedure was 4.6 -Emergent operations had a significantly higher post-operative complication rate across all complications with the exception of wound infection and urinary tract infections. -Among different  62 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation operation types (laparoscopic appendectomy, laparoscopic cholecystectomy, enterectomy with anastamosis, partial colectomy with anastamosis, and partial colectomy with colostomy and distal stump) complex procedures had significantly higher risk or morbidity/mortality as compared to similar non-emergency procedures  Factors affecting morbidity in emergency general surgery   Akinbami, F. 2011 The American Journal of Surgery What are the predictors of postoperative complications of emergency general surgery?  Retrospective analysis using NSQIP database 819 ACS-NSQIP predetermined factors in addition to 18 more Post operative mortality and morbidity within 30 days (surgical site infections, sepsis, respiratory (unplanned intubation, pulmonary embolism, pneumonia, on ventilator �48 h), urinary (acute renal fail- ure, urinary tract infection), neurologic 2007-2009 -Respiratory and surgical site infections were the two most common complications post operatively -Mortality rate at 30 days post-op in this population was 8.9% - age, sex, length of surgery, increased blood glucose levels, increased BUN level,  63 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation (cerebrovascular accident), and cardiac (myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation) occurrences) deteriorating functional health status, ASA class of 3 or higher, presence of COPD, and history of smoking were found to be significant predictors of postoperative complications    Predictors of relaparotomy after nontrauma emergency general surgery with initial fascial closure Kim, JJ. et. al. 2011 The American Journal of Surgery Identify patients at risk for relaparotomy after nontrauma intraabdominal catastrophes (NTIAC)  Retrospective analysis 129 patients with NTIAC and primary fascial closure Findings on history and physical exam, progress notes, intra-operative findings, postoperative Acute Physiology and Chronic Health Evaluation III scores. relaparotomy 1998-2008 Independent risk factors were: peripheral vascular disease, alcohol abuse, body mass index of 29 kg/m2 or greater, the finding of any ischemic bowel, and operating room latency of 60 hours or longer. Renal Insufficiency Predicts Mortality in Geriatric Patients Undergoing Emergent General Surgery Yaghoubian, A. et. al. 2011 The American Surgeon To determine the incidence of post operative complications and the predictors of mortality in geriatric patients undergoing emergency general surgery Retrospective analysis 44 patients Age, gender, preoperative serum creatinine level. Revised Cardiac Risk Index (RCRI), history of comorbidities, including ischemic Post operative morbidity and mortality 2003-2009 Serum creatinine was higher in patients who died.  64 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation heart disease, congestive heart failure (CHF), insulin-dependent diabetes mellitus (DM), and cerebrovascular accident (CVA). Systemic inflammation worsens outcomes in emergency surgical patients Becher, RD. et. al. 2011 Journal of Trauma To determine the relationship between systemic inflammation and postoperative complications in patients undergoing emergent colon surgery Retrospective analysis using ACS-NSQIP database 3,305 patients Presence or absence of inflammation (Systemic inflammatory response syndrome), sepsis, severe sepsis and septic shock Post operative morbidity and mortality 2008 Thirty-day survival was significantly different among different levels of inflammation/sepsis with hazard ratios increasing significantly with increasing severity of inflammation   Impact of a regional acute care surgery model on patient access and outcomes  Kreindler, SA. et. al. 2012 Canadian Journal of Surgery To evaluate the effect of implementation of an emergency general surgery service on patient access and outcomes Retrospective analysis 14735 observations Emergency admission throughout the time span of the study Time to surgery, length of stay, readmission and complications 2005-2009 Regionalization showed no impact on length of stay, readmission, complications or mortality Longer waiting times for patients who needed transfer from non-referral hospitals Effect of handover on the outcomes of small bowel obstruction in an acute care surgery model Lien, I. et. al. 2012 ANZ Journal of Surgery To evaluate the impact of patient handover in an ACS model on the outcomes of adhesive small bowel obstruction (SBO) Retrospective analysis  50 control patients pre-ACS 110 handed over 61 were not Patients handed over compared to those who were not Operative details, and morbidity and mortality, overall length of hospital stay (emergency department arrival to hospital discharge), time September 2005 to February 2011 In the ACS period, there was no significant difference in complication rates or length of hospital stay in those who were  65 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation from admission to surgery and post-operative stay in days. not handed over and those who were. There were no significant differences in complication rates or length of hospital stay in the pre-ACS and ACS period but there was a trend towards reduced complications in ACS group. Key Performance Indicators in an Acute Surgical Unit: Have We Made an Impact? Hsee, L. et. al. 2012 World Journal of Surgery Describe the Current acute patient pathway, present the early trend of KPIs for the ASU and determine whether an impact has been made on acute surgical patients.  Retrospective analysis Not specified Pre and post ASU  (1)Time to assess referred patients from the emergency department (ED) and from GPs [where patient assessment occurs in the assessment and planning unit (APU)]; (2) preoperative length of stay (LOS[PO]); (3) length of stay of non-admitted patients (LOS[NA]); (4) case volume ‘‘in h’’ (0730–1730) versus ‘‘after h’’; and (5) readmission rate. Pre-ASU: 2008 up to May 2009 Post-ASU: May 2009- January 2010 Reduce time to referral from ED, reduced time to referral from GP. No significant difference in overall pre-operative LOS but a decrease in appendectomy PO-LOS. Increase in “in hours” operative cases. Outcomes in the Cubas, RF. et. al. 2012 Journal of the To determine the impact of ACS of Retrospective analysis  175 appendectomy  Pre and post ACS Key time intervals, complication Pre-ACS: July 2009 to June Appendectomy group: reduced  66 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation Management of Appendicitis and Cholecystitis in the Setting of a New Acute Care Surgery Service Model: Impact on Timing and Cost American College of Surgeons timing and cost 113 laparoscopic cholecystectomy patients rates. 2010 Post-ACS: July 2010 to June 2011 time to surgical evaluation, time to OR, length of stay and complication rates.  Cholecystectomy group: similar findings as appendectomy group. Cost of care was significantly reduced in the ACS model. Comparison of Hospital Performance In Trauma vs Emergency and Elective General Surgery Implications for Acute Care Surgery Quality Improvement Ingraham, AM. et. al. 2012 Archives of Surgery Compare quality of care between emergency general surgery and trauma surgery, and trauma and elective general surgery. Retrospective analysis Trauma: 32557 ELGS: 120256 EMGS: 14239 Trauma, elective general surgery and emergency general surgery Morbidity and mortality National trauma data bank-2007 ACS NSQIP 2005-2008 No differences in morbidity or mortality between groups. Failure-to-Pursue Rescue Explaining Excess Mortality in Elderly Emergency General Surgical Patients with Preexisting “Do-Not-Resuscitate” Scarborough, JE. et. al. 2012 Annals of Surgery To describe outcomes of elderly patients with DNR orders who undergo emergency general surgery and describe the relationship between pre-operative DNR status and mortality. Retrospective analysis using ACS NSQIP data 25558 patients DNR: 1061patients Non-DNR: 24497 patients DNR versus non-DNR status Primary outcome: 30-day mortality rates Secondary outcomes: 30-day major postoperative complication rate, failure-to-rescue rate (defined as postoperative mortality in the setting of 1 or 2005-2010 DNR patients had significantly higher mortality rates as compared to non-DNR patients despite being matched and having similar rates of post-operative complications. DNR patients are less likely to  67 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation Orders more major complications), reoperation within 30 days of the index procedure, and length of postoperative hospitalization (assuming postoperative survival). undergo a re-operation, and are more likely to die to from a major post-operative complication than non-DNR patients. Acute appendicitis: A disease severity score for the acute care surgeon Garst, GC. et. al. 2012 Journal of Trauma and Acute Care Surgery A new Disease Severity Score to predict post operative outcomes in acute appendicitis Retrospective analysis 918 patients diagnosed with acute appendicitis DSS score  Mortality, length of stay, in-hospital and post-discharge complications 1999-2009 Greater DSS score was significantly associated with adverse outcomes in general and is also significantly associated with each outcome individually (increased length of stay, surgical site infection, intra-abdominal abscess, post-discharge small bowel obstruction)  Mortality in high-risk emergency general surgical admissions Symons, NRA. et. al.  2013 British Journal Of Surgery To quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts. Retrospective analysis 367796 patients from 145 hospitals 30 day mortality rate, adjusting for patient and hospital factors High and low mortality outlier hospitals 2000-2009 Number of Intensive Care unit beds, use of CT scan and ultrasound were independent predictors of lower mortality rates. Low mortality rate hospital trusts had higher number of intensive care unit  68 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation beds per 1000 hospital beds, and used CT scan and US more frequently. Comparison of appendicectomy outcomes: acute surgical versus traditional pathway Pillai, S. et. al. 2013 ANZ Journal of Surgery To compare the performance of the ASU at Auckland City Hospital with the traditional model. Retrospective analysis 875 traditional model 982 ASU model Traditional model and ASU model Key Performance Indicators (KPIs): Length of stay, surgical complications, return to theatre, re-admission, time to theatre, weekend discharge rate, proportion of operations during daylight hours, duration of operation, time from referral to review, mortality ASU (from June 2008 to December 2010) Traditional model (from January 2006 to May 2008) There was a significant reduction in the LOS and the proportion of daytime operations.  Other key performance indicators showed a trend towards improvement but not statistically significant. Does an Acute Surgical Model increase the rate of negative appendicectomy or perforated appendicitis? Brockman, S.F. et. al. 2013 ANZ Journal of Surgery To evaluate the effect of the Acute Surgical Model on the management of appendicitis, in particular the Negative appendectomy and perforated appendectomy rates. Retrospective analysis 357 patients in ASM 351 in traditional model Traditional model and ASM  Negative appendicectomy, perforated appendicitis, appendicitis/ appendiceal pathology, alternative pathology, mortality, wound infection, intra-abdominal collection, re-admission (pain), re-operation, icu admission, respiratory infection, myocardial infarct Traditional model (2010) ASM (2011) No significant difference in PA or NA rates. No difference in complications. Significantly less overnight procedures.  69 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation  Effect of the introduction of an emergency general surgery service on outcomes from appendicectomy Suen, K. et. al. 2013 British Journal of Surgery To assess the outcomes of appendectomy before and after the introduction of a consultant-led emergency general surgery (EGS) service at a large metropolitan tertiary referral center. Retrospective analysis 276 pre EGS 399 post-EGS Pre-EGS status compared to post-EGS Time to surgery, hospital length of stay, use of radiological investigations, negative appendectomy rate and perforation rate. July 2008 to December 2009 (before introduction of the EGS service) And following the introduction of the service from January 2011 to June 2012. Increase time to surgery; increase daytime appendectomies, no change in length of stay, and no difference in negative appendectomy rates or perforated appendectomy rates. Impact of an Acute Care Surgery Model with a Dedicated Daytime Operating Room on Outcomes and Timeliness of Care in Patients with Biliary Tract Disease Lim DW, et. al.  2013 World Journal of Surgery To evaluate the effect that an ACS model with a dedicated daytime operating suite would have on outcomes and timeliness of care in patients with biliary tract disease Retrospective analysis 72 pre-ACS and 172 post-ACS Pre-ACS and post ACS on all operative biliary disease patients Post operative complications, time from admission to operation, operative time, and length of hospital stay 1 July 2005 to 30 June 2006, and from 1 July 2007 to 30 June 2009 Shorter time from admission to OR, decreased number of patients awaiting operation Impact of an acute care surgery model on appendicectomy outcomes Poh, BR. et. al. 2013 ANZ Journal of Surgery The impact of the ASU on the outcomes in an appendectomy population. Retrospective analysis  A total of 539 patients, 283 in the ASU model and 256 not in the model. Pre and post ASU implementation Time measures, negative appendectomy rates, perforated appendicitis rate, laparoscopic appendectomy, surgical site infections, use of imaging  From July 2010 to June 2012 Reduced proportion of procedures performed during the nighttime.    Implementation of the acute care surgery Fu, CU. et. al  2013 American Journal of Surgery The impact of the ACS model on surgical efficiency Retrospective before and after 146 pre-ACS 159 post ACS Pre and post ACS in patients with acute Time indicators, post operative complications Pre-ACS: August 2009 to July 2011 Hospital length of stay and ED length of stay were  70 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation model provides benefits in the surgical treatment of the acute appendicitis and quality in patients with acute appendicitis study appendicitis (perforated appendicitis, other complications), application rate of CT scan  ACS: August 2010 to July 2011 significantly less in the ACS group. There was no difference in complication rates between the two groups.    Quality of life and long-term outcomes of octo- and nonagenarians following acute care surgery: a cross sectional study Gazala, S 2013 World Journal of Emergency Surgery To assess post-operative cognitive impairment, functional status, and quality of life in elderly patients who underwent emergency surgery. Retrospective analysis  159 patients 1, 2 and 3 years post emergency surgery Abbreviated Mental Test Score-4, Barthel Index, Vulnerable Elders Survey, and EuroQol-5 Dimensional Scale. 2008-2010 More patients had cognitive impairments at 3 years (33.3%) than at 1 (9.5%) and 2 years (9.1%) post-operatively. No statistical difference in the ability to carry out activities of daily living or functional decline with increasing time post-operatively Stapled versus hand-sewn anastomoses in emergency general surgery: A retrospective review of outcomes in a unique patient population Farrah, JP. et. al. 2013 Journal of Trauma and Acute Care Surgery To compare outcomes of hand-sewn (HS) versus stapled (ST) bowel anastomoses in EGS patients. Retrospective analysis 100 hand sewn 133 stapled anastomosis 231 patients Hand sewn versus stapled anastomosis  Operative time, anastomotic failure, mortality, hospital days, type of bowel anastomosed. 2007-2011 Operative time was shorter in stapled anastomosis.  Anastomotic leak was significantly higher in stapled anastomosis. A model-based evaluation of the Canberra Hospital Acute Care Surgical Beardsley, CJ. et. al 2014 Surgery Today To compare outcomes before and after implementing the Surgical Retrospective analysis 150 patients Presence or absence of an acute care surgical unit (SAPU) Time to casualty doctor review, tine to general surgical review, time from casualty 2010-2011 All outcomes measures apart from casualty review and CT investigation were  71 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation Unit Assessment and Planning Unit (SAPU) using acute appendicitis as the model disease.  to surgical review, time to operating table, time to discharge, after hours operating and presence of radiological imaging per patient significantly reduced after introduction of the SAPU Outcomes after emergency general surgery at teaching versus nonteaching hospitals Zafar, SN 2014 Journal of Trauma and Acute Care Surgery To compare outcomes in emergency general surgery patients in teaching and non-teaching hospitals Retrospective analysis  3,707,465 patients from 3,163 centers  Teaching and non-teaching hospitals Major complications, length of stay, cost and mortality 2005-2011 Minimal difference in the odds between the two groups in all different outcomes Sustainability and Success of the Acute Care Surgery Model in the Nontrauma Setting O’Mara, MS. et. at. 2014 Journal of The American College of Surgeons To evaluate outcomes related to the introduction of the acute care surgery model in the nontrauma setting Retrospective analysis 497 pre-ACS cases 2634 post ACS cases grouped by year Pre and post ACS establishment status Complication rates, length of stay, costs 2007-2011 Reduction in complication rates, shorter hospital stay and reduction in costs The Acute Surgical Unit Model Verses the Traditional ‘‘On Call’’ Model: A Systematic Review and Meta-Analysis Nagaraja, V. et. al.  2014 World Journal of Surgery To perform a systematic review and meta-analysis of literature comparing the acute care surgical model to the traditional on call model for the diagnoses of acute appendicitis, cholecystitis and small bowel obstruction Systematic review and meta-analysis 18 studies Traditional model and ACS model Appendicitis: presence of perforation,  post-operative complications, conversion to open and negative appendectomy rates Acute cholecystitis: conversion to open, post-operative complications and All available literature up to November 2013 There is a significant reduction in almost all outcome parameters in different conditions except negative appendectomy rate and perforated appendicitis rate which were similar in both groups  72 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation length of stay  Small bowel obstruction: no sufficient data  An acute care surgery service expedites the treatment of emergency colorectal cancer: a retrospective case–control study Anantha, RV. et. al. 2014 World Journal of Emergency Surgery To assess the impact of an Acute Care and Emergency Surgery Service (ACCESS) on wait-times for inpatient colonoscopy and surgical resection among emergency CRC patients. Retrospective case control study 149 patients (47 pre-ACCESS, 37 post-ACCESS, and 65 non-ACCESS) Pre and post ACCESS Colonoscopy, surgery rates and median wait time until colonoscopy and surgery for patients diagnosed with CRC Pre-ACCESS (July 1, 2007-June 31, 2010), post-ACCESS (July 1, 2010-June 30, 2012) More patients underwent inpatient colonoscopy as compares to pre-ACCESS. All patients post ACCESS underwent colonoscopy and surgery within the same admission as compared to 44% of patients only in the pre-ACESS era. Predictors of in-hospital mortality and complications in very elderly patients undergoing emergency surgery Merani, S. et. al.  2014 World Journal of Emergency Surgery To examine the outcomes in very elderly patients undergoing emergency general surgery, including predictors of in-hospital mortality and morbidity. Retrospective analysis 170 patients Comorbidities, surgical indications, and perioperative risk assessment data Length of hospitalization, discharge destination, and in-hospital mortality and morbidity. 2008-2010 ASA and development of in-hospital complications were independent predictors for mortality. Sarcopenia is a predictor of outcomes in very elderly patients undergoing emergency surgery Du, Y. et. al. 2014 Journal of Surgery To determine if sarcopenia is a predictor of morbidity and mortality in elderly patients undergoing emergency surgery  Retrospective analysis 170 patients Presence versus absence of sarcopenia Post-operative morbidity and mortality. 2008-2010 More sarcopenic patients had complications as compared to non-sarcopenic patients An acute care surgery dilemma: Joseph, B. et. al. 2014 The American Journal of To describe hemorrhagic complications in Retrospective analysis 112 patients Taking versus not taking aspirin therapy Intraoperative hemorrhage, postoperative 2010-2011 No difference in outcomes between the two  73 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation emergent laparoscopic cholecystectomy in patients on aspirin therapy Surgery patients on pre-hospital aspirin (ASP) therapy undergoing emergent cholecystectomy anemia, need for blood transfusion, and conversion to open cholecystectomy groups in all outcomes measures A composite index for predicting readmission following emergency general surgery  Muthuvel, G et. al. 2014 Journal of Trauma and Acute Care Surgery To determine predictors associated with 30 day re-admission in EGS patients as compared to Elective patients Retrospective analysis using ACS-NSQIP database 625 EGS patients 3343 elective patients  Surgical Apgar Score (SAS), American Society of Anesthesiologists Physical Status Classification and length of stay in elective versus emergency patients Readmission  2006-2012 EGS patients have a higher readmission rate (11.1% vs. 15.2%, p = 0.004)  SAS and ASAPSC were both associated with a higher readmission rate Trainee Participation Is Associated With Adverse Outcomes in Emergency General Surgery Kasotkis, G. et. al. 2014 Annals of Surgery To identify whether trainee participation is associated with clinically relevant outcomes in patients undergoing emergency general surgical procedures. Retrospective analysis 83790 patients Resident involvement as compared to no resident. Morbidity and mortality 2005-2010 Trainee participation is independently associated with intra- and postoperative events, wound, pulmonary, and venous thromboembolic complications, and urinary tract infections. Laparoscopic versus open surgical management of small bowel obstruction: an analysis of short-term outcomes Saleh, F. et. al.  2014 Journal of Surgical Endoscopy To compare short-term postoperative outcomes in patients with adhesive SBO treated with laparotomy versus Retrospective analysis using ACS NSQIP 4,616 patients  3,697 open  919 laparoscopic Laparoscopic versus open surgical management  Morbidity, mortality, operative time 2005-2010 Mean operative time was similar. Overall morbidity and complication rates were significantly higher in the open group as compared to the laparoscopic  74 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation laparoscopy. group. Adjusted OR for overall complications in the laparoscopic group was 0.46 times that for open surgery. A composite index for predicting readmission following emergency general surgery  Muthuvel, G et. al. 2014 Journal of Trauma and Acute Care Surgery To determine predictors associated with 30 day re-admission in EGS patients as compared to Elective patients Retrospective analysis using ACS-NSQIP database 625 EGS patients 3343 elective patients  Surgical Apgar Score (SAS), American Society of Anesthesiologists Physical Status Classification and length of stay    Readmission  2006-2012 EGS patients have a higher readmission rate (11.1% vs. 15.2%, p = 0.004)  SAS and ASAPSC were both associated with a higher readmission rate Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery St-Louis, E. et. al. 2014 Journal of Trauma and Acute Care Surgery To evaluate the role of the Charlston age-comorbidity index (CACI) in predicting peri-operative outcomes in emergency general surgery patients Retrospective analysis 529 emergency general surgery admissions  CACI score Morbidity and mortality 2010 CACI score was associated with an increased risk of 30-day mortality  National estimates of predictors of outcomes for emergency general surgery Shah, AA. et. al.  2014 Journal of Trauma and Acute Care Surgery To determine the predictors of in-hospital complications and mortality among EGS patients. Retrospective analysis  6,712,151 discharge records representing 32,910,446 visits for EGS conditions. Patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics Major complications (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital 2003-2011 Uninsured patients were more likely to die. patients with the highest income were the least likely to die. Old age was an independent factor for  75 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation (location, teaching status, and bed size). mortality. mortality. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease. Racial/ethnic disparities in emergency general surgery: explained by hospital-level characteristics? Hall, EC. et. al. 2015 The American Journal of Surgery To quantify racial/ethnic differences in outcome after emergency general surgery (EGS). Procedures included were colectomies, small bowel obstruction and ulcer repair. Retrospective analysis 116344 patients Caucasian versus African American Post-operative mortality 2000-2008 African American patients had 10% higher odds of dying after EGS than Caucasian patients.  The excess morbidity and mortality of emergency general surgery   Havens, JM et. al.  2015 Journal of Trauma and Acute Care Surgery To quantify the excess burden of morbidity and mortality associated with EGS by controlling for patient-specific factors   Retrospective analysis using ACS-NSQIP database 66,665 patients, 24,068 were EGS and 42,597 were NEGS   ACS-NSQIP predetermined measures in elective versus emergency patients The primary outcome was death within 30 days of operation. Secondary outcomes were postoperative complications.   2008-2012   When preoperative variables and procedure type were controlled, EGS was independently associated with death (odds ratio, 1.39; p = 0.029) and major complications (odds ratio, 1.31;  76 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation p = 0.001). Predictors of mortality and morbidity for acute care surgery patients Sudarshan, M. et. al. 2015 Journal of Surgical Research To investigate Prognostic risk factors to predict unfavorable outcomes: mortality, post-operative complications, ICU admission and prolonged hospital stay Retrospective analysis 527 EGS admissions 37 factors obtained form history, physical examination and laboratory values, operative details,  Charlston co-morbidity index, efficiency parameters for patient flow  In-hospital Mortality, occurrence of postoperative complications, need for ICU admission, a prolonged length of hospital stay, and change in autonomous discharge disposition 2010 -Use of anti-coagulants, -I-----independent predictors for mortality included hypotension, leukopenia, use of anticoagulants and hypothermia. -Predictors on post operative complications include smoking, leukopenia and tachycardia. -factors associated with ICU admission were tachypnea, leukopenia, leukocytosis and use of anticoagulants. -Advanced age, higher ASA score, tachycardia and presence of complications were associated with longer hospital stay.  Acute Care Surgery: Defining Mortality in Emergency General Surgery in the State of Maryland Narayan, M. et. al. 2015 Journal of The American College of Surgeons To compare mortality among EGS patients treated in a trauma center versus a non-trauma center. Retrospective analysis  817942 patients  Trauma center versus non-trauma center status in different strata of All Patients refined Severity of Illness (APR-SOI) In hospital mortality 2009-2013 No difference in mortality rates for minor APR-SOI. Mortality was significantly lower for moderate APR-SOIs treated in trauma centers as compared to non- 77 Study Authors/institution Date Journal Research question Design Number Outcome measures Main outcomes Length of follow up Interpretation trauma centers. TC status was associated with higher mortality rates in extreme APR-SOIs.  Emergency general surgery outcomes at safety net hospitals Shahan, CP. et. al. 2015 Journal of Surgical Research To compare the outcomes of emergency general surgery procedures performed at safety net and non safety net hospitals. Retrospective analysis 187913 patients Safety versus non safety net hospitals. Length of stay, charge, cost, death in hospital, complications, and failure to rescue (FTR). 2008-2010 Safety net hospitals have a higher risk of morbidity but not mortality or FTR.  Impact of specific postoperative complications on the outcomes of emergency general surgery patients McCoy, CC. et. al. 2015 Journal of Trauma and Acute Care Surgery Identify to contribution of certain post-operative complications on mortality rates following emergency general surgery. Retrospective analysis using ACS NSQIP data 43429 patients Post operative complications Post operative mortality 2005-2011 Incisional surgical site infection had the highest Incidence, followed by pneumonia. Stroke, major bleeding, myocardial infarction, and pneumonia exhibited the strongest associations with postoperative death.    

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