Joaquim Michael Havens

Objective: We aimed to assess the association between hospital operative-to-nonoperative management ratio (ONR) and home discharge for older adults undergoing Emergency General Surgery (EGS). Summary Background Data: There is an increasing number of patients being managed nonoperatively, particularly older adults, which have often been excluded from quality benchmarking. The ONR might serve as a better marker of hospital quality, instead of the traditional morbidity/mortality, which do not fully capture institutional practice patterns nor what matters most to older adults (ie, their ability to return home). Methods: This was a retrospective analysis of the National Inpatient Sample database (2015-2018). For each hospital, we calculated a risk-adjusted ONR for adults >=65 years with common EGS diagnoses (diverticulitis, bowel obstruction, acute pancreatitis, peptic ulcer, ischemic bowel, appendicitis, and cholecystitis) who underwent urgent/emergent surgery within 48 hours. Hospital operative volume was also calculated to serve as comparison to ONR. Both metrics were then divided into tertiles. Our primary outcome was home discharge. Multivariable regression analyses evaluated the impact of ONR/Operative volume on our main outcome. Results: Among 1,470,114 EGS admissions, 207,270 (14.1%) older adults underwent EGS. The mean ONR was 0.28 (SD 0.07). After adjusted analysis, care at hospitals within the highest ONR tertile was significantly associated with higher odds of home discharge (OR 1.10, 95% CI: 1.06–1.14). Hospital operative volume was not associated with discharge to home. Conclusions: An increased hospital operative-to-nonoperative management ratio of EGS conditions in the geriatric population is strongly associated with increased odds of a favorable discharge home.

Emergency general surgery (EGS) requires acute management of high-risk surgical patients, necessitating rapid and accurate risk stratification for informed decision-making and quality benchmarking. The American Association for the Surgery of Trauma Patient Assessment Committee has previously identified six criteria for an ideal risk stratification tool for EGS. These include the ability to accurately quantify morbidity and mortality risk in the EGS population, use readily obtainable objective data, be applicable early-prior to surgical intervention, be applicable in non-operative patients, can be used for auditing purposes, and application that facilitates use in clinical practice.1

BACKGROUND Quality benchmarking has recently evolved from a historical focus on short-term morbidity and mortality as the key metrics to assessing long-term outcomes. Long-term quality metrics have been shown to provide a more complete assessment of geriatric trauma care. Among these metrics, patients' average number of healthy days at home (HDAH) proports to be a useful administrative claims-based marker of patient functional status. Our goal was to determine the predictors of HDAH among injured older adults. METHODS Medicare inpatient claims (2014–2015) were used to identify all geriatric trauma patients. Patients' number of HDAH was measured from the date of discharge and calculated as the total sum of patients' time during that period less any time spent in the hospital or emergency department, step-down/rehabilitation/nursing care, home health, or after death within a 365-period after index admission. Controlling for demographic, injury severity, and hospital-level characteristics, multivariable regression analyses were performed to identify the factors associated with increased HDAH. RESULTS We included 772,109 geriatric trauma patients. The mean age was 82.15 years (SD, 8.49 years), 68.3% were female, and 91.6% were White. The median HDAH was 351 days (interquartile range, 351–355 days). After adjusted analysis, age, Black race, Charlson Comorbidity Index (CCI), and care at a level 3/nontrauma center were associated with fewer HDAH within 365 days after discharge. CONCLUSION This study suggests that higher level trauma centers provide more HDAH after index admission for injured older adults. Future studies should focus on correlating HDAH with more granular but less readily accessible quality of life metrics. LEVEL OF EVIDENCE Prognostic and Epidemiological; III. Export

Background: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra‐ and postoperative aspects of care.Methods: Experts in aspects of management of high‐risk and emergency general surgical patients were invited to contribute by the International ERAS^® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta‐analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS^® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.Results: Twenty‐three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.Conclusions: These guidelines are based on best available evidence for an ERAS^® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high‐risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Background: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.Methods: Experts in management of the high‐risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta‐analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.Results: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.Conclusions: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end‐of‐life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high‐risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high‐risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.Methods: Experts in aspects of management of the high‐risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta‐analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non‐emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1.Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds.Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high‐risk patients.