Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.
Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.
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改善急诊普通外科手术的结果：构建协作质量计划。
DOI：
10.1097/ta.0000000000004248
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发表时间：
2024
期刊：
影响因子：
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通讯作者：
Napolitano,LenaM
中科院分区：
文献类型：
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作者：
Hemmila,MarkR;Neiman,PoojaU;Hoppe,BeckieL;Gerhardinger,Laura;Kramer,KimA;Jakubus,JillL;Mikhail,JudyN;Yang,AmandaY;Lindsey,HughJ;Golden,RoyJ;Mitchell,EricJ;Scott,JohnW;Napolitano,LenaM
急诊普外科是一种常见、昂贵且高度病态的疾病。由于卫生系统和护理过程的差异而造成的过度发病率所占比例尚不清楚。我们构建了急诊普外科的协作质量倡议，以调查急诊普外科提供的护理并指导流程改进。方法收集2019年7月- 2022年12月10家医院的数据。定义了五个队列：急性阑尾炎、急性胆囊疾病、小肠梗阻、紧急剖腹手术和总体聚集。调查的过程和住院结果包括手术与非手术治疗、死亡率、发病率（死亡率和/或并发症）、再入院率和住院时间。多变量风险调整考虑了人口统计学、合并症、解剖学和疾病特征的变化。结果19956例急诊普外科患者中，女性占56.8%，白人占82.8%，平均（SD）年龄为53.3（20.8）岁。在考虑患者和疾病因素后，调整后的总死亡率为3.5%(95% CI, 3.2-3.7)，发病率为27.6%(95% CI, 27.0-28.3)，再入院率为15.1%（95% CI, 14.6-15.6）。不同医院的手术处理情况不同，急性阑尾炎70.9% ~ 96.9%，小肠梗阻19.8% ~ 79.4%。在对整个队列的死亡率、发病率和再入院率进行风险调整后，观察到不同医院之间的结果有显著差异。在患有小肠梗阻的患者中，使用胃grafin的比例从10.7%到61.4%不等。在最初接受非手术治疗的急性胆囊炎患者中，51.5%的患者放置了胆囊造瘘管。各医院胆囊造瘘管置入率为23.5% ~ 62.1%。结论多院急诊普外科合作的发病率高，且各医院在过程和结果上存在较大差异。有针对性的协作质量改进工作可以识别急诊普外科护理的异常值，并可能提供优化结果的机制。
BackgroundEmergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements.MethodsWe collected data at ten hospitals from 7/2019-12/2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative vs. non-operative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits.ResultsOf the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were white, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5%(95% CI, 3.2-3.7), morbidity 27.6%(95% CI, 27.0-28.3), and the readmission rate was 15.1%(95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high-and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial non-operative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals.ConclusionsA multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes.