Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center

Key Takeaways

Emergency general surgery (EGS) patients may bypass local hospitals with adequate resources to care for patients.

Introduction

The number of admissions for EGS diagnoses has increased substantially over the last 20 years. There are now roughly 4 million EGS-related admissions annually, and the incidence is greater than 1 in 100 for the US population. ¹ In the United States, more than 80% of EGS operations are attributable to one of seven operations—appendectomy, cholecystectomy, colectomy, laparotomy, lysis of adhesions, peptic ulcer disease, and small bowel resection. ² Although EGS cases comprise only 11% of operative cases, they account for 47% of mortalities and 28% of complications. ³ EGS operations account for substantial portion of health care expenses, costing over $28 billion dollars to the US health care system in 2010; by 2060, it is estimated the number will grow to $41.7 billion dollars. ⁴

At many hospitals and health care systems, the demand for EGS operations taxes the supply of surgeons and operating room time. Most tertiary centers are often at capacity and thus face operational challenges when accepting complex patients and transfers from other facilities in the region. EGS patients who require operative intervention may be placed on operating room “wait lists” if there is no dedicated EGS operating room or if there is one and it is over capacity, which can lead to delays in definitive management. Frequently being at or over bed capacity can result in an increase in the number of patients in intensive care units and wards and lead to decreased nurse to patient ratios. The volume of EGS patients may also place a strain on the ability to schedule elective cases at busy and at-capacity tertiary hospitals. Some have argued for EGS regionalization of high-risk patients to these highly utilized tertiary facilities, through a process of triage and transfer based on physiologic, resource, surgeon, and patient factors. However, complete transfer of all EGS volume would likely result in inundated tertiary facilities with no ability to have patient throughput and efficiency due to high-volume, low-acuity patients. A middle ground of the right patient, to the right facility, with the right resources, right operation, and as close to home as possible, is the true goal of EGS regionalization.

Therefore, we hypothesized that given the wide variation in EGS disease severity and patient comorbidities there would be a subset of patients who could have been safely cared for at a non-tertiary care hospital, to possible free up bed capacity and utilize resources closer to home. Many modern health care systems operate multiple facilities with varying levels of capacity and resources which could be coordinated and optimized to care for EGS patients. By shifting patients in a certain geographic area to underutilized facilities, potentially closer to the patient’s home location, the strengths of a health care system can be used to offload the operative volume for less complex cases. The idea of regionalization of EGS, similar to the trauma tiered system, has been proposed to improve patient care and outcomes. ⁵ While there are some data for complex EGS operations showing increased volume is associated with improved outcomes, most routine EGS operations are performed by general surgeons at smaller centers with similar results to tertiary centers. ⁶ Additionally, these data show that EGS outcomes are improved when EGS operations are performed by high-volume surgeons regardless of center type.^7,8

Consequently, the debate as to the benefits and drawbacks of regionalization is an ongoing one in the EGS community. Despite the controversy, all sides would likely agree that improved EGS regional coordination would improve the utilization of resources for the system and potentially free up resources to care for most complex and severely ill patients. Therefore, to evaluate the potential impact of EGS regionalization and system-level coordination of care, the authors analyzed our EGS population at a large tertiary care referral hospital, to identify patients with a home zip code in geographical proximity to a hospital with less capacity challenges. The purpose of this study was to use geocoding to identify patients admitted to a tertiary care facility who lived geographically closer to an underutilized regional hospital with EGS capabilities. We hypothesized that it would be possible to identify a subset of patients with low-acuity EGS diagnoses who are geographically closer to a regional hospital. If so, this population could be used to identify future opportunities for enhanced EGS system management. Specifically, with the recent creation of an acute care surgery network within our health care system, this may identify patients for increased coordination of care.

Methods

Results

During the study time frame, a total of 60 604 EGS patient encounters were identified, and 14 714 (24.3%) encounters were at our tertiary facility. A heat map with a generalized area of distribution for the zip codes in the southern region is displayed in Figure 1. Most patients were directly admitted to the hospital (92.75%); however, 1067 (7.25%) were admitted from another hospital. Overall, 1526 (10.4%) of the 14 714 EGS admissions required an operation. RHA patients accounted for 4454 (30.2%) of all encounters and 527 (34.5%) of all patient operations. The two patient groups were not statistically different regarding age, BMI, or CCI (P < .05 for all variables, Table 1). However, there were specific comorbidities that contribute to the CCI that were significantly less common in the RHA group including myocardial infarction, congestive heart failure, cerebrovascular accident, moderate liver disease, and end-stage renal disease. COPD and hemiplegia were found to be more frequent in the RHA patient group; P < .05 for all.

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Figure 1.

This figure shows a heat map indicating the relative concentration of emergency general surgery patients in varying parts of the metropolitan area. Red is indicative of the largest number of patients, followed by orange, yellow, and finally green (fewest patients). The area closer to the regional hospital is sectioned off in the right-hand corner.

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Table 1.

Patient Characteristics.

	LA (n = 9819)	RHA (n = 4281)	P value
Age (years ± SD)	52.6 ± 18.1	52.5 ± 18.1	.49
BMI (kg/m2 ± SD)	28.4 ± 14.0	28.2 ± 10.5	.32
CCI score	3.8 ± 3.5	3.8 ± 3.5	.11
Comorbidities
Myocardial infarction	7.9%	6.3%	< .01
Congestive heart failure	14.8%	12.8%	< .01
PAD	11.2%	10.1%	.07
Cerebrovascular accident	8.9%	7.8%	.03
Dementia	1.7%	2.0%	.19
COPD	26.1%	30.4%	< .01
Connective tissue disorder	3.7%	3.5%	.59
Peptic ulcer disease	6.6%	5.9%	.17
Mild liver disease	16.1%	15.0%	.08
Moderate liver disease	5.0%	3.7%	< .01
DM uncomplicated	26.6%	25.3%	.11
DM w/complications	6.4%	6.0%	.40
Hemiplegia	5.1%	5.4%	< .01
End-stage renal failure	19.1%	17.9%	.08
Malignancy	11.7%	12.5%	.15
Metastatic disease	5.0%	5.5%	.26
AIDS	1.9%	2.2%	.19

Abbreviations: AIDS, acquired immunodeficiency syndrome; BMI, body mass index; CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; LA, local admission; PAD, peripheral artery disease; RHA, regional hospital admission.

The volume of EGS patients by diagnosis type is displayed in Figure 2. The most common EGS diagnosis categories for RHA patients were abdominal operations, soft tissue, and UGI. The only EGS diagnosis category in which there was statistically significant difference between RHA and LA patients was “resuscitation” (5.9% vs. 7.8%; P < .01) which was more common at the tertiary facility. The most common operations performed were cholecystectomy (20.1%) and appendectomy (31.1%). Thus, nearly half of the operations were comprised of more complicated procedures such as laparotomy, colectomy, and small bowel resection. The most common operations performed in RHA patients were similarly appendectomy (38.3%) and cholecystectomy (28.2%, Figure 3) and were more likely to undergo cholecystectomy and appendectomy than their LA counterparts (P < .01 for both).

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Figure 2.

Admission volume is shown here by AAST defined emergency general surgery category groups. The orange part of the bar graph corresponds with regional hospital admission patients and the blue with local admission patients. Abdominal operations were most frequently performed.

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Figure 3.

Specific operations performed are shown in this figure. The orange part of the bar graph corresponds with regional hospital admission patients and the blue with local admission patients. Appendectomy and cholecystectomy were the most performed operation for both the regional hospital admission and local admission groups.

Mortality at 30-day, 90-day, 1-year, and 3-year increments was significantly lower for RHA patients (P ≤ .05 for all, Table 2). Length of stay was not significantly different between the two groups (RHA 5.5 days, LA 5.7 days; P = .06).

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Table 2.

Mortality and Length of Stay.

	LA (n = 9819)	RHA (n = 4281)	P value
30-day mortality	7.1%	6.1%	.03
90-day mortality	10.2%	8.8%	.01
1-year mortality	16.3%	13.9%	<.01
3-year mortality	23.6%	20.1%	<.01
Length of stay (days) ± SD	5.7 ± 8.7	5.5 ± 9.0	.06

Discussion

Nearly one-third of the EGS patient population at our tertiary care facility were patients who lived closer to the southern regional hospital. Almost two patients per day could potentially be cared for at the regional hospital rather than our tertiary care facility and provide care closer to the patient’s home. The RHA patients that contribute to the EGS volume at the tertiary care facility have patient demographics like the LA patients but had a lower incidence of complex surgeries. This feasibility study was designed to investigate the possibility of creating systems to direct appropriate patients to a nearby large hospital rather than a tertiary care regional referral center. It provides initial evidence that EGS regionalization that includes directing lower acuity patients to closer facilities, at least in our system, could be used to optimize patient care and system efficiency. While further work on this topic needs to be done, this could be an important first step in true EGS regionalization and a robust coordination of regional EGS care.

Both RHA and LA patients contribute to the complex nature of EGS cases at the tertiary center demonstrated in Figure 2. It is notable that there were a disproportionate number of RHA patients who underwent appendectomies and cholecystectomies as compared to the LA patients. This suggests that patients are not coming to the tertiary care center due to complex surgical needs, and in fact these cases are the ones that ideally could be performed safely, and possibly more efficiently, at our southern region facility given their lower complexity with good outcomes and low mortality. ¹² The higher percentage of RHA patients undergoing appendectomy and cholecystectomy likely also contributed to the lower mortality that was demonstrated for RHA patients at each of the measured time intervals. However, additional data to risk-stratify patients would be beneficial in assessing the difference in mortality.

There are already initiatives within our health care system that are helping to localize surgical care in communities around the city. For example, another hospital in the northeast section of the city is establishing a surgical critical care service to provide the full spectrum of care for complex surgical patients. Currently, that hospital provides trauma and EGS services, and the addition of surgical critical care makes this facility complete with regards to acute care surgery capabilities. ¹³ Additionally, starting a new EGS service line at a second regional hospital just north of the city has led to increased and closer access for a population with a high percentage of minority and low socioeconomic status patients. Utilizing a different approach, patients who present to the tertiary facility with appendicitis or cholecystitis without significant comorbidities are being transferred to a community hospital, less than two miles away, for their definitive surgical management to decrease time to operation and to free up operative availability at the tertiary care center.

Recently, these types of initiatives have been codified and organized into an acute care surgery network that operates and coordinates care at the various facilities within the regional health system. The focus of the network’s initiatives has currently been to focus on increasing surgeon communication and inter-facility coordination, create evidence-based guidelines, facilitate a peer reviewed EGS outcomes meeting, and importantly discuss barriers and solutions to facility resource gaps and transfer difficulties. This type of open dialog and collaboration facilitates easier dissemination of information, guidelines, transfer agreements, and additionally repatriation of patients to facilities closer to their homes. Much work must be performed before this structure can be evaluated for impact on patient outcomes, but this study provides evidence that there is room to optimize even a highly integrated system like our own through such a structured collaborative network.

The transfer of patients from a tertiary care hospital to a regional hospital is a novel approach considering the reverse is typically more common. ¹⁴ Transfers to tertiary care hospitals from smaller hospitals have not been shown to be associated with better outcomes—rather national studies have shown that transferred patients may have an increased 30-day mortality and more complications.^15,16 This may be partially explained by increased comorbidities or severity of illness in transferred patients or delayed recognition of illness, which can occur in situations of perceived or actual lack of access to EGS care. ¹⁷ Early recognition of emergency general surgical issues and capacity for surgical intervention at regional hospitals could improve outcomes for patients in surrounding communities. In the future, it is important that our health system be able to adequately market and advertise the surgical services offered at smaller, regional facilities since it is known that patients may live closer to these facilities. An emphasis on marketing for our different hospital locations is essential in achieving patient confidence and may drive patients to present to local emergency departments and receive timely and appropriate care.

Limitations of this study fall into two main categories. The first is that not all patients with EGS diagnoses are appropriate for surgery at a non-tertiary hospital given comorbidities and severity of illness. For instance, patients that need immediate resuscitation in the ICU or have significant cardiopulmonary limitations at baseline may be better served at a center with increased critical care and other consult services in the perioperative period. While the number of patients transferred was small (7.25%), the reason for transfer was not known. More importantly, the reason for patients directly presenting for admission, despite living closer to the other facility was not known either and could be due to a number of factors. Specifically, transplant and cardiovascular patients with EGS-related problems would justifiably be more likely to present to their specialty tertiary center. However, the equivalent comorbidity score and decreased mortality in this population would argue against this being solely the reason. Proponents might argue that there is a volume-outcome relationship with EGS operations, with high-volume centers having better outcomes and less complications, which were not assessed in this study.^18,19 This volume-outcome effect, however, appears to be mitigated by surgeon volume. Low complexity cases, such as appendectomies, are least likely to benefit from this volume relationship. ²⁰ The second limitation is that there are other variables besides absolute distance that determine ultimate location of patient care. Factors that may influence patient choice include familiarity with a facility, location of facility close to work or other family members, and public transportation or traffic patterns that make it more convenient for patients.

Future efforts should focus on developing more complex geocoding algorithms to include such aforementioned factors and should focus on outcomes other than mortality and length of stay, such as readmission rates after surgery, functional outcomes, costs associated with hospitalization, failure to rescue, and very importantly, patient reported outcomes. Additionally, it will be important to evaluate costs of transfer to another facility in relation to the cost of delayed surgery and prolonging hospital stay vs. cost savings for not transferring. Ultimately, coordination of care for the EGS patient through a regionalized structure, to get the right patient, to the right facility, with the right resources and surgeon will be a challenging goal for the next decade. However, increasing communication, collaboration, and partnerships between community and tertiary facilities is paramount to improve the care of this large but underrecognized population.