Morad Hameed

The concept of trauma systems is a generally agreed upon principle in the world of trauma, where patients access appropriate care for their injuries in an appropriate time frame, resulting in rehabilitation and reintegration into society. The literature favours care of the severely injured at tertiary centers, thus a system is formed to pull the patient to the ideal center of care. Though theoretical frameworks exist, how the system is actualized remains ambiguous, variable, and difficult to capture. Current system measurements perhaps are not reflecting system actualization, especially for non-tertiary centers with no staff assigned to surveillance of the injured patient through the system. After a scoping review of the literature, it was found that secondary triage and subsequent under-triage could be a significant indicator of system function and actualization. Thus, a retrospective chart review was done at a non-tertiary center to assess system function through secondary triage to tertiary care. All injured patients transferred to a tertiary center from a level 3 trauma center between January 1, 2017-December 31, 2017 were reviewed. Inpatient transfers were used to reflect under triage. It was found that patients had a 50% likelihood of being appropriately triaged when they met the major trauma patient criteria of the health authority. Call times to the patient transfer network were poorly documented and showed significant delay of access to care. As well, results showed a significant underuse of general surgery consultation with only 5 of the 27 patients being seen by the service, 4 of them were then transferred from the emergency department. Though this site has theoretical system planning, support tools, and algorithms—actualization was variable and showed an underappreciation for the injuries and their sequelae. Exploring tools to decentralize surveillance and influence include a using a simple Cribari Matrix to calculate an under-triage rate, applying a Learning Health Systems cycle, and drawing on High Reliability Organization principles to optimize care. Ultimately, culture will drive practice, therefore it is imperative that we drive culture with relentless intention to best influence the care of the injured.

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Background:Dedicated emergency general surgery (EGS) services have been established across North America as a means to bring focus and quality to a large, complex and vulnerable surgical population. The emergence of these services represents a great opportunity to understand and improve emergency surgical care. Methods:This research programs applies a health systems structure/process/outcomes framework to the study of EGS services in Canada: 1. OUTCOME: A systematic review of the effects of an EGS service on patient and non-patient related outcomes2. STRUCTURE: A national cross sectional study of structure and case mix on 14 EGS services 3. PROCESS: Detailed process mapping of a complex EGS condition Results:1. OUTCOMES: Studies found increased daytime and decreased after-hours operating, improved patient transit from ED to OR to home, and decreased length of stay after implementation of an EGS service. The overall trend was higher more diverse case volumes, which improved resident education. Lower complication rates were noticed in the appendicitis and cholecystitis groups. 2. STRUCTURE: Canadian EGS services demonstrated variability in service organization and access to operating rooms. However, a national cross sectional study of EGS patients revealed that all services see diverse case mix and high complexity, and routinely make complex judgments about operative and non-operative care.3. PROCESS: The processes of care for small bowel obstruction (SBO) patients from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration. Data visualization strategies were used to identify substantial variability in terms of time to CT scan and time to OR.Conclusions:The EGS model has been implemented worldwide, and has demonstrated an improvement in timeliness of care, decreased administrative costs, and improved trainee learning. EGS services are well-established in Canada, and poised to identify new opportunities for improved patient care. Process mapping has been successfully integrated into surgical specialties and provides insight into potential areas of performance improvement in EGS.

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Background: According to the literature, up to 30% patients with colorectal cancers (CRCs) present to the emergency department (ED) with surgical emergencies. The most common surgical presentations of these patients are: intestinal obstruction, perforation and bleeding. Palliative surgical interventions in these patients are believed to carry high risks of morbidity and mortality. Moreover, management options tend to be individualized in most cases, if not all.Methodology: A systematic review of published literature was conducted. Articles meeting inclusion criteria were summarized. Quantitative data regarding study characteristics were analyzed and expressed as descriptive statistics. Primary outcomes of interest were post-operative complications, mortality and 5-year disease free status.Results: 304 articles were collected from searching online data bases. Eight articles were found to match the research question and underwent a full text review. Five more articles were added from searching the grey literature. After final review, 11 articles were selected to be included in the systematic review. Papers were assessed for methodological validity. 81.8% of studies used regression models in their analyses. Mean number of patients included in the papers was 3,567 (min= 145, max= 30,790). 50.2% of all patients were males. Most of the included studies reported mean age of more than 60 years. The mean follow-up period in days was 399.5. Analysis of different variables revealed that, CRC patients who received emergency surgery had more comorbidities (95% CI, OR=1.42 P=0.05), higher American Society of Anesthesiology classes (95% CI, OR=1.33 P=0.08), and more advanced disease (95% CI, OR=1.09 P=0.02) than CRC patients who receive surgical intervention on elective basis. Moreover, resection rate was higher in the elective group (95% CI, OR=0.5 P=0.04). In contrast, stoma creation rate was higher in the emergency group (95% CI, OR=5.08 P=0.003). Furthermore, emergency patients had higher rates of postoperative complications (95% CI, OR=4.6 P=0.007) and mortality (95% CI, OR=5.38 P=0.0001). Conclusion: Patients requiring emergency surgery for CRC often have complex comorbidities and acute instability, and are at very high risk of postoperative complications. These findings highlight an important opportunity for the development of comprehensive systems of emergency surgical care, and, ultimately, improvement of patient outcomes.

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Background:Emergency General Surgery (EGS) patients have unique physiologic characteristics and are at a high risk of complications compared to elective general surgery patients. We aimed to perform a scoping review of the literature that examines predictors of outcomes in EGS patients. Methodology:A scoping review of published literature from 2004 to May 2015 was conducted in Medline, EMBASE, Cochrane library and PubMed. Keywords were chosen based on the three most common diagnoses in EGS; acute appendicitis, cholecystitis and small bowel obstruction, in addition to emergency general surgery, acute care surgery, outcomes & post-operative complications. Articles meeting inclusion criteria were summarized. Quantitative data regarding study characteristics were analyzed and expressed as descriptive statistics. Qualitative data from included studies were grouped intro predictors based on a framework derived from a grounded theory approach to content analysis. Primary outcomes of interest were post-operative morbidity and mortality. A predictor was included if it was significantly correlated with an outcome based on a minimum of bivariate analysis. Results:A total of 715 articles were identified during the primary search, of those 62 were found to be relevant to the search criteria. Almost all of the studies were retrospective. The median number of patients in these studies was 1000 (IQR 266,20896) with a mean of median/mean age reported of 53.2 years. Average length of follow up was 4.6 years. There were 54 predictors of outcome identified and these were grouped into patient related, process related and structure/system related predictors. The most frequently reported predictor of any adverse outcome was absence of an EGS system, followed by an ASA score of 3 or more. The most frequently reported predictor of post-operative morbidity was absence of EGS system. The most frequently reported predictor of mortality was age ≥ 65, emergency status and ASA ≥ 3.Conclusion:EGS patients are at a higher risk of post-operative adverse outcome as compared to elective surgical patients. System implementation significantly improves outcomes in this patient population. Identifying what predicts adverse outcomes can help in future risk assessment scores, planning future prospective trials and improving performance in emergency general surgery systems.

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