From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (M.P.DW., K.A.D., K.M.S., S.P.E., A.A.M., R.D.B.), Yale School of Medicine, New Haven, Connecticut.
J Trauma Acute Care Surg. 2018 Aug;85(2):348-353. doi: 10.1097/TA.0000000000001939.
Patients requiring emergency surgery have increased rates of morbidity and mortality. Transfer from outside institution delays effective control of ongoing infection and has been linked with worse outcomes. Previous research suggests transfer status negatively impacts survival but has not examined the effect of location and type of institution prior to transfer. This study aims to characterize the effect of type of transferring institution on postoperative outcomes after emergency colon surgery.
Data originated from the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2012. Patients undergoing emergent colectomy were stratified based on location: not transferred, transferred from outside emergency department (ED), transferred from outside hospital inpatient unit, or transferred from a nursing home. Patient variables were stratified and compared via χ and analysis of variance. A backward-multivariable logistic regression and adjusted multivariate Cox regression analysis were performed to determine factors predicting 30-day mortality.
A total of 14,245 patients were identified, of whom 22% (3,203) were transfer patients. Among transfers, 48% (1,531) came from outside hospital inpatient units. Thirty-day mortality varied significantly (p < 0.001) among transfer location: 12.8% when not transferred, 19.4% from outside EDs, 25.7% from outside hospital inpatient units, and 34.2% from nursing homes. Hazard ratios were 1.30 (p < 0.001) after transfer from outside hospital inpatient ward and 1.50 (p < 0.001) after transfer from nursing home. Patients transferred from nursing homes were more likely to have septic shock (26.9% vs. 11.6%, p < 0.001) and longer hospitalizations (13 days vs. 10 days, p < 0.001) versus those not transferred.
Transfer status is an independent contributor to death in emergency general surgery patients undergoing colectomy. Patients transferred from an outside hospital ED, nursing home or chronic care facility have the poorest outcomes. These results reinforce the importance of rapid triage and transfer of patients with early physiologic decompensation to ensure timely surgical evaluation and intervention.
Prognostic, level III; Therapeutic, level IV.
需要紧急手术的患者发病率和死亡率较高。从外部机构转院延迟了对正在进行的感染的有效控制，并与更差的结果相关。先前的研究表明，转院状态对生存率有负面影响，但并未检查转院前机构的类型和位置对结果的影响。本研究旨在分析转院机构的类型对急诊结肠手术后术后结果的影响。
数据来源于美国外科医师学会国家手术质量改进计划数据库，时间为 2010 年至 2012 年。根据患者的所在地，将接受紧急结肠切除术的患者分层：未转院、从外部急诊室（ED）转院、从外部医院住院部转院或从疗养院转院。通过卡方检验和方差分析对患者变量进行分层比较。采用向后多变量逻辑回归和调整后的多变量 Cox 回归分析来确定预测 30 天死亡率的因素。
共确定了 14245 名患者，其中 22%（3203 名）为转院患者。在转院患者中，48%（1531 名）来自外部医院住院部。转院地点的 30 天死亡率差异显著（p < 0.001）：未转院者为 12.8%，从外部 ED 转院者为 19.4%，从外部医院住院部转院者为 25.7%，从疗养院转院者为 34.2%。从外部医院住院病房转院后的危险比为 1.30（p < 0.001），从疗养院转院后的危险比为 1.50（p < 0.001）。从疗养院转院的患者更有可能发生感染性休克（26.9%比 11.6%，p < 0.001）和住院时间更长（13 天比 10 天，p < 0.001）。
转院状态是急诊普通外科患者接受结肠切除术死亡的独立危险因素。从外部 ED、疗养院或慢性病护理机构转院的患者预后最差。这些结果强调了对早期生理失代偿患者进行快速分诊和转院的重要性，以确保及时进行手术评估和干预。
预后，III 级；治疗，IV 级。
