Department of Surgery, University of Wisconsin, Madison, WI.
Department of Surgery, University of Massachusetts Medical School, Worcester, MA.
Ann Surg. 2019 Aug;270(2):270-280. doi: 10.1097/SLA.0000000000002746.
To examine national adherence to emergency general surgery (EGS) best practices.
There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data.
A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression.
The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries.
There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.
考察全国范围内对急诊普通外科（EGS）最佳实践的遵循情况。
普通外科急症的高质量医疗服务获取存在全国性危机。急性外科手术（ACS）作为利用创伤系统优势的专业学科，可能会缓解这一危机。创伤护理的一个关键组成部分是遵守临床指南。我们之前使用 RAND 适宜性方法和试点数据为 EGS 制定了最佳实践。
一项采用混合（邮寄/电子）问卷调查的方式，对美国所有符合条件的成人急性普通外科综合医院中负责 EGS 的人员（n=2811）进行了 20 项 EGS 最佳实践的遵循情况调查。使用双变量方法和多变量逻辑回归对问卷结果进行了分析。
回复率为 60.1%。遵循情况从 EGS 登记的 8.5%到术后 30 天再入院的审核 86.2%不等。对于不限于 EGS 的实践（如审核再入院），其遵循程度高于 EGS 特定实践（如登记、激活系统）。采用 ACS 护理模式增加了推迟择期手术、分级紧急手术、遵循国家综合癌症网络指南、逆转抗凝剂、审核返回重症监护、评估时间、手术时间和源头控制时间的实践的遵循程度，以及具有接受患者的转移协议、重症监护入院协议，以及 EGS 特定的激活系统、门诊、发病率和死亡率会议和登记。
在性能改进方面仍有很大的空间，采用 ACS 模式预测会有更好的表现。这是对 EGS 最佳实践遵循情况的全新概述，将使外科医生和政策制定者能够解决全国范围内 EGS 护理的差异。
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