Surgical Rescue in a High-volume Urban Emergency General Surgery Service at a Middle-income Country

INTRODUCTION

Recent evidence demonstrates that complications across surgical specialties in the United States do not differ from high- to low-volume hospitals. However, mortality varies according to the speed and proper measures from acute surgical care to the “rescue” of patients with complications, such as death. Failure to “rescue” these patients with complications has been recently regarded as an important indicator of patient safety and quality of care.^1–6 Subsequently, hospitals can be divided in terms of quality, into high-performing and low-performing hospitals according to their capacity to surgically rescue patients from complications.

In our high-volume emergency general surgery (EGS) academic service (805 beds) in a middle-income country, an automatic electronic EGS registry was developed for quality control to automatically capture in-hospital information and outcomes from the Electronic Medical Record (EMR) since there is no option to buy commercial acute care registries or hire registrars to capture databases.

The primary aim of this study is to describe the incidence of surgical rescue failure, defined as the inability to prevent death in emergency surgical patients with complications, in our academic healthcare center. Our secondary objectives were to define the quality of care of EGS cases through the electronic automatic EGS registry in our institution and to compare quality indicators from our service against international standards.

MATERIALS AND METHODS

STATISTICAL ANALYSIS

The data were processed by the authors with the statistical software SPSS version 20.0. Descriptive measures were described as the mean ± standard deviation or median (interquartile range). To identify the association between the clinical variables and complications, the Chi-square test or Fisher’s exact test was employed as appropriate. The normality of the quantitative variables was evaluated with the Kolmogorov–Smirnov and Shapiro–Wilk tests. The differences between the averages with Student’s t-test were determined for two independent groups with homogeneous or heterogeneous variances. This assumption was previously evaluated with the Levene test, and in the case of distributions other than normal, the nonparametric asymptotic Wilcoxon–Mann–Whitney test was used. Values of α <0.05 were considered statistically significant (p < 0.005).

RESULTS

Of 962 emergency surgical procedures performed at the Hospital Universitario Mayor—Mederi in Bogota, Colombia, during June and July 2017, 91.7% (n = 882) corresponded to EGS in 501 patients. The mean age of these EGS patients was 53.9 ± 20.9 years, and 56.5% were female. Table 1 presents the distribution and time to surgery of the initial top 10 EGS procedures performed.

Of these 501 patients, 2.6% (n = 13) presented with an EGS surgical complication, confirmed by the medical record. The overall EGS mortality was 6.7% (n = 33): 1.0% (n = 5) within 24 hours, 0.2% (n = 1) between 25 and 48 hours, and 5.4% (n = 27) 48 hours after admission.

The surgical rescue failure rate, which was defined as the inability to prevent death after a surgical complication, was 2/13 (15.4%).

The most common complications requiring surgical rescue interventions in the operating room (2.6%, n = 13) were anastomotic leakage (38.5%, n = 5), uncontrolled sepsis (30.8%, n = 4), and hemorrhage (30.8%, n = 4). The surgical rescue interventions performed were source control of infection (38.5%, n = 5), hemorrhage control (30.8%, n = 4), bowel resection (23.1%, n = 3), and wound debridement (7.7%, n = 1). The cause of non-planned surgical intervention for the two patients we failed to rescue was an anastomotic leak.

The median time of surgery for all rescue patients was 5.1 hours. Table 2 depicts the time to surgery for the surgical rescue patients according to mortality.

In terms of outcomes, the surgical rescue patients were significantly more prone to be admitted to the hospital and have a longer hospital length of stay than the non-rescue patients. Table 3 shows the outcomes of the EGS patients with surgical complications.

DISCUSSION

The collection of reliable data and outcomes to support surgical quality improvement programs in low- and middle-income countries (LMICs) has become one of the top public health priorities.^7,8 We described here the surgical failure to rescue rate (15.4%), overall 30-day mortality (6.7%), and complications requiring surgical rescue interventions (2.6%) in the largest academic medical institution in Colombia over 2 months. All our surgical rescue procedures were solved in the operating room. The most common causes for surgical rescue in our cohort were anastomotic leakage (38.5%), uncontrolled sepsis (30.8%), and hemorrhage (30.8%). The surgical rescue interventions were source control of infection (38.5%), hemorrhage control (30.8%), bowel resection (23.1%), and wound debridement (7.7%). The cause of non-planned surgical intervention for the two patients we failed to rescue (15.4%) was an anastomotic leak. Surgical rescue patients had significantly higher admission rates to the hospital than non-rescue patients [100% (n = 13) vs 77.5%, p < 0.05] and had a longer hospital length of stay [22.7 ± 24.9 (n = 10) vs 11.2 ± 14.3, p < 0.01]. Admission to the ICU (30.8 vs 11.9%), need for mechanical ventilation (15.4 vs 8.4%), and in-hospital mortality (15.4 vs 6.6%) were also higher in the surgical rescue group than in the nonrescue group but did not reach statistical significance.

Recent publications in the US have demonstrated that EGS patients are 8 times more prone to die after surgery, present 50% more postoperative complications, and have a 14% more likely to be readmitted than patients undergoing the same surgical procedure electively.^9,10 The EGS diagnosis represents almost 7% of all hospital admissions in the US, embodying a yearly cost of more than $28 billion.¹¹ Unfortunately, in Colombia, the burden of disease of EGS patients has not yet been estimated. From a previous (2013) nonpublished research paper by the authors in our institution, we proposed a registry for the quality follow-up of EGS patients to describe the quality of care in acute care surgery patients and compare our performance with the international standard of care. From this retrospective review of the clinical records of 231 EGS consecutive patients over a month, the 30-day postoperative mortality was 3.46%, the severe complication rate was 8.04%, the in-hospital stay length was 6.54 days ± 5.18, and the intensive care unit stay length was 5.7 days ± 4.42, similar to the outcomes described by Ingraham et al.^12,13

Hospital Universitario Mayor is the largest healthcare institution in Colombia with a high surgical volume. Despite having only one operating room devoted to emergency procedures for all specialties, EGS operations were promptly performed according to national and international standards. The median time to surgery was 4.1 hours for appendectomy, 6.0 hours for abdominal exploration, and 17.3 hours for laparoscopic cholecystectomy. Our surgically rescued patients also underwent prompt intervention (median 5.1 hours). Additionally, surgical rescue failure patients (patients with complications who died) were significantly more promptly operated on than the surgical rescue patients who survived (2.15 vs 5.20 hours, p = 0.013), indicating our readiness to intervene in the more defiant cases.

“Failure to rescue” has become an important marker of quality of care, since mortality and morbidity have been identified as incongruous markers, and the variance in mortality is derived from the capacity of prompt and successful “rescue” of surgical patients from complications. Our failure to rescue rate in our EGS cohort was similar to that described in recent publications.^14–16 Our data correspond to a prospective study of surgical complications, different from most of the literature where records come from retrospective administrative registries, with less capacity to detect all the complications.¹⁵ As previously described by Kutcher et al.,¹⁶ the hospital admission and hospital stay of surgical rescue patients were significantly higher than those of the non-surgical rescue group. The plausible explanation for not reaching a significant difference for outcomes, such as admission to the ICU, need for mechanical ventilation and in-hospital mortality between the complicated cases vs non-complicated cases is the small size of our cohort.

CONCLUSION

The surgical failure to rescue rate (15%) in our institution was similar to the rate recently described in comparable high-volume EGS services in the US. Surgical rescue patients more commonly required critical care and mechanical ventilation, longer hospital and ICU length of stay, and were less likely to be discharged to home than patients without complications. The in-hospital mortality rate was also higher in surgical rescue patients than in non-rescue patients. The development and implementation of an electronic automatic captured EGS registry database in our academic medical center serves to build best practices for “surgical rescue” and to drive quality improvement programs.

We have created at our institution an affordable system to monitor the quality of care in EGS that helps to plan hospital resources and define surgical quality improvement programs. The development and implementation of an electronic automatic captured EGS registry database in our academic medical center serves to build best practices for “surgical rescue” and to drive quality improvement programs.

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