Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
J Surg Res. 2020 Jun;250:172-178. doi: 10.1016/j.jss.2019.12.051. Epub 2020 Mar 5.
Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations.
National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations.
There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy.
Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.
急诊普通外科（EGS）的死亡率通常归因于患者状况，这可能掩盖了改善护理的机会。确定救援失败（FTR）或并发症后死亡可能揭示这些机会。由于次要创伤的优先顺序率较低（并发症前死亡的比例），FTR 一直存在问题。我们试图在 EGS 中评估这一点，假设 EGS 的优先顺序低于类似的择期手术。
使用 2014 年 1 月至 2015 年 9 月的国家住院患者样本数据。通过紧急入院、七个国际疾病分类，第九版（ICD-9）中常见 EGS 手术程序组代码之一和手术时间（<48 小时）定义了 150027 例成人急诊普通外科完整病例；这些代表了国家住院患者样本抽样设计下的 750135 名患者。如果确定了八个预定并发症之一，则认为死亡是有先例的。卡方检验用于比较选定的急诊和择期手术的优先顺序率。
该队列的 EGS 手术患者死亡率为 2.5%，优先顺序率为 84.1%（95%CI：82.7%-85.4%）。在列出的七个程序组中，那些具有临床合理的择期模拟的是胆囊切除术、结肠切除术和剖腹术。结肠切除术的急诊与择期优先顺序率分别为 90.2%和 82.0%（P=0.004），胆囊切除术为 81.3%和 86.8%（P=0.26），剖腹术为 68.8%和 92.7%（P<0.001）。
EGS 的优先顺序率高于预期，与之前发表的非紧急手术中的优先顺序率相似，这表明使用标准方法，FTR 可能是可靠的。在急诊手术后处理并发症可能是预防死亡率的重要机会。
