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Background: Emergency general surgery (EGS) patients are at an increased risk for morbidity and mortality compared with non-EGS patients. Limited information exists regarding the contribution of malnutrition to the outcome of critically ill patients who undergo EGS. We hypothesized that malnutrition would be associated with increased risk of 90-day all-cause mortality following intensive care unit (ICU) admission in EGS patients.Materials and Methods: We performed an observational study of patients treated in medical and surgical ICUs at a single institution in Boston. We included patients who underwent an EGS procedure and received critical care between 2005 and 2011. The exposure of interest, malnutrition, was determined by a registered dietitian's formal assessment within 48 hours of ICU admission. The primary outcome was all-cause 90-day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models.Results: The cohort consisted of 1361 patients. Sixty percent had nonspecific malnutrition, 8% had protein-energy malnutrition, and 32% were without malnutrition. The 30-day readmission rate was 18.9%. Mortality in-hospital and at 90 days was 10.1% and 17.9%, respectively. Patients with nonspecific malnutrition had a 1.5-fold increased odds of 90-day mortality (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.09-5.04; P = .009) and patients with protein-energy malnutrition had a 3.1-fold increased odds of 90-day mortality (adjusted OR, 3.06; 95% CI, 1.89-4.92; P < .001) compared with patients without malnutrition.Conclusion: In critically ill patients who undergo EGS, malnutrition at ICU admission is predictive of adverse outcomes. In survivors of hospitalization, malnutrition at ICU admission is associated with increases in readmission and mortality. [ABSTRACT FROM AUTHOR]

Recent advances in genetic testing can help to provide a specific diagnosis to children born with syndromes that result in congenital anomalies and developmental delay. One such emerging condition is the 22q13 deletion syndrome. With the introduction of subtelomeric fluorescencein-situ hybridization (FISH) analysis, the 22q13 deletion has become recognized as a relatively widespread and underdiagnosed cause of mental retardation. Primary-care physicians play an important role in the care of children with 22q13 deletion syndrome, from suspecting the diagnosis in a developmentally delayed child through the medical, developmental, and behavioral aspects of their care. Furthermore, they serve as a valuable source of support and advocacy for the family and a resource for other care providers. The remainder of this article addresses the current state of knowledge regarding 22q13 deletion syndrome and offers the primary-care physician a framework in which to provide care and information. [ABSTRACT FROM AUTHOR]

Background: Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system., Methods: All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group., Results: A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged., Conclusion: Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2022 American Association for the Surgery of Trauma.)

Background: Surgical devices are implicated in approximately 15% of intraoperative interruptions and 25% of errors. Device-related interruptions (DRIs) are therefore an important target for surgical quality improvement, but scalable measurement methodologies are lacking. The researchers therefore developed, pilot tested, and refined a simple tool for assessing intraoperative DRIs., Methods: Five DRI categories achieved face validity with frontline providers and surgical safety experts: improper/challenging assembly, device failure, loss of sterility, disconnection, and absent/wrong device. A data collection tool was created based on these categories as well as a free-text section to capture emergent DRI categories. After a brief training session, the tool was pilot tested by observers at a large academic referral center., Results: In a sample of 210 operations, observers noted 66 DRIs across 39 cases. DRIs were most common in colorectal (38.0 per 100 cases), gynecologic (33.3 per 100 cases), and hepatopancreatobiliary surgery (32.1 per 100 cases). Device failure accounted for 30.3% of observed DRIs. Three emergent categories were identified: user unfamiliarity with the device (15.2%), video display malfunction (4.5%), and physical breakage of the device (1.5%)., Conclusion: Measurement of DRIs by novice observers is a feasible and scalable approach to support quality improvement efforts focusing on surgical devices. This approach could provide actionable insights to improve device safety, such as informing educational and training programs, optimizing surgical tray composition, and improving the physical layout of the operating room., (Copyright © 2022 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: The majority of cases of idiopathic acute pancreatitis (IAP) are thought to result from occult biliary disease. A growing body of evidence suggests that cholecystectomy for IAP reduces the risk of recurrence by up to two thirds. This study examined nationwide uptake and disparities in adoption of cholecystectomy for IAP., Methods: The National Inpatient Sample was queried to identify admissions for IAP between October 2015 and December 2018. Patients who underwent cholecystectomy before discharge and those that did not were compared using Wald χ 2 tests for categorical variables and Student's t test for continuous variables. Patient- and hospital-level predictors of cholecystectomy were identified using weighted multivariable logistic regression., Results: Of 62,305 estimated admissions for IAP, only 665 (1.1%) underwent cholecystectomy before discharge. Female sex, initiation of total parenteral nutrition (TPN), insurance status, and hospital type were associated with cholecystectomy on univariable analysis. On multivariable analysis, Hispanic patients (odds ration [OR] 1.60, 95% confidence interval [CI] 1.01-2.56), patients on TPN (OR 2.70, 95% CI 1.17-6.24), and those with private insurance (OR 2.18, 95% CI 1.48-3.21 versus Medicare/Medicaid) were more likely to receive operations. Small hospitals and hospitals in rural areas were least likely to perform empiric cholecystectomies., Conclusion: Despite increasing evidence supporting cholecystectomy after IAP, the practice remains rare in the United States. Educational efforts and active implementation efforts are needed to promote adoption. Particular attention should be focused on small, rural centers and those that disproportionately care for uninsured patients and patients with public insurance., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Non-technical skills are critical to surgical safety. We examined the impact of the COVID-19 pandemic on non-technical skills of operating room (OR) teams in Singapore., Materials and Methods: Observers rated live operations using the Oxford NOTECHS system. Pre- and post-COVID observations were captured from November 2019 to January 2020 and from January 2021 to February 2021, respectively. Scores were compared using Schuirmann's Two One-Sided Test procedure. Multivariable linear regression was used to adjust for case mix. A 10% margin of equivalence was set a priori., Results: Observers rated 159 cases: 75 pre-COVID and 84 post-COVID. There were significant differences between groups in surgical department and surgeon-reported case complexity (both P < 0.001). Total NOTECHS scores increased post-COVID on raw analysis (36.1 vs 38.0, P < 0.001) but remained within the margin of equivalence (90% CI 1.3 to 2.6, P < 0.001). Multivariable analysis demonstrated a similar increase within the margin of equivalence (2.0, 90% CI 1.3 to 2.7). Teamwork and cooperation scores increased by 1.0 post-COVID (90% CI 0.8 to 1.3); all other subcomponent scores were equivalent., Conclusion: Non-technical skills before and after the peak of the COVID-19 pandemic were equivalent but not equal. A small but statistically significant improvement post-COVID was driven by an increase in teamwork and cooperation skills. These findings may reflect an improvement in team cohesion, which has been observed in teams under duress in other settings such as the military. Future work should explore the effect of the pandemic on OR culture, team cohesion, and resilience., (Copyright © 2022 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: The COVID-19 pandemic has forced a creative transition to virtual platforms due to physical distancing and travel restrictions. We designed and tested a highly scalable virtual training curriculum for novice raters using the Oxford NOTECHS non-technical skills rating system., Design: A three-day training course comprising virtual didactics, virtually facilitated simulations, and independent live observations was implemented. NOTECHS scores were submitted for eleven standardized video simulations and four live operations. Intraclass correlation coefficients (ICCs) were calculated for total NOTECHS scores and subcomponent scores. Raters previously trained in-person with the same standardized videos served as a comparator group for equivalence testing., Setting: All study activities were conducted in a large academic tertiary referral center in Singapore as part of an ongoing surgical safety initiative., Participants: Seven staff members underwent training (three virtually and four in-person).  None had prior surgical experience or non-technical skills assessment training., Results: ICCs for total NOTECHS scores were 0.85 (95% CI, 0.73-0.98) for virtually trained raters and 0.83 for those trained in-person (95% CI, 0.68-0.99).  Scores were equivalent between groups within a 10% margin., Conclusions: Non-technical skills assessment can be reliably taught in a highly scalable virtual format. Virtual NOTECHS training is a valuable tool for educational and quality improvement initiatives during the COVID-19 pandemic and for centers that lack ready access to onsite non-technical skills training expertise., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool., Methods: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression., Results: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories., Conclusion: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach., Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1., Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds., Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Objective: To our knowledge, no curricula have been described for training novice, nonclinician raters of nontechnical skills in the operating room (OR). We aimed to report the reliability of Oxford Non-Technical Skills (NOTECHS) ratings provided by novice raters who underwent a scalable curriculum for learning to assess nontechnical skills of OR teams., Design: In-person training course to apply the NOTECHS framework to assessing OR teams' nontechnical skill performance, led by 2 facilitators and involving 5 partial-day sessions of didactic presentations, video simulation, and live OR observation with postassessment debriefing. NOTECHS ratings were submitted after each of 11 video scenarios and 8 live operations for the total NOTECHS team rating (including surgical/anesthesiology/nursing subteams) and for each NOTECHS skill category-situation awareness, problem solving and decision making, teamwork and cooperation, leadership and management. Inter-rater reliability was determined by calculating the intraclass correlation coefficient (ICC, range 0-1)., Setting: Training for outcome measurement during a quality improvement initiative focused on surgical safety in 3 public hospitals in Singapore. Two trainings were conducted in May 2019 and January 2020., Participants: Ten novice raters who were existing hospital staff and had overall minimal OR experience and no prior experience with nontechnical skill assessment., Results: ICC for the total NOTECHS team rating was 0.89 (95% confidence interval [CI], 0.87-0.91). ICCs for each NOTECHS category were as follows: situation awareness, 0.83 (95% CI, 0.78-0.88); problem solving and decision-making, 0.76 (95% CI, 0.70-0.83); teamwork and cooperation, 0.84 (95% CI, 0.79-0.88); leadership and management, 0.81 (95% CI, 0.75-0.86)., Conclusions: This training curriculum for nontechnical skill assessments of OR teams was associated with high inter-rater reliability from novice raters with minimal collective OR experience. Using scalable training materials to produce reliable measurements of OR team performance, this nontechnical skills assessment curriculum may contribute to future QI projects aimed at improving surgical safety., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Changes in care providers and hospitals after emergency general surgery (EGS) (care discontinuity) are associated with increased morbidity and mortality. The cause of these worse outcomes is unknown. Our goal was to determine if hospital quality is associated with mortality after readmissions independent of continuity in care., Study Design: This was a retrospective analysis of Medicare inpatient claims (2007 to 2015). All inpatients older than 65 years of age who underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally, were included. Care discontinuity was defined as readmission within 30 days to a nonindex hospital. Hospital quality was determined by hospital-level, risk-adjusted mortality rates by EGS procedure and categorized into high quality (HQ) and low quality (LQ). The primary outcome was overall mortality. Multivariate logistic regression analysis was used to determine the association of discontinuity and mortality., Results: There were 882,929 EGS patients, 87,232 of whom were readmitted within 30 days of discharge. Care discontinuity was independently associated with mortality (odds ratio [OR] 1.23; 95% CI 1.17 to 1.29). When readmitted patients were stratified by quality of index and readmitting hospital, mortality was associated with the quality of both the index hospital and the readmitting hospital. The highest mortality rate was observed in patients with index admission at low-quality hospitals and readmission to a different low-quality hospital., Conclusions: Both care discontinuity and hospital quality are independently associated with mortality in EGS patients. These data support maintaining continuity of care, even at low performing hospitals., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Emergency general surgery (EGS) encompasses high-risk patients undergoing high-risk procedures. Admission source, particularly interhospital transfer, is rarely accounted for in clinical performance benchmarking. Our goal was to assess the impact of transfer status on outcomes after EGS., Study Design: This was a retrospective analysis of the American College of Surgeons NSQIP database (2005 to 2014). All inpatients that underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally were included. Admission source was classified as directly admitted vs transferred from an outside emergency department or an acute care facility. The primary outcomes were overall mortality, overall morbidity, and major morbidity. A 3:1 propensity score matched analysis was used to determine the association of admission source with outcomes. Subgroup analysis was performed for high- and low-risk EGS procedures., Results: A total of 222,519 EGS admissions were identified, of which 15,232 (6.8%) were transfers. Mean age was 46 years and 51.4% were female. Overall mortality was 3.1% for the entire cohort and 10.8% within the transfer group. After propensity score matched analysis for 33 clinical and demographic variables, transferred patients had higher rates of overall mortality (odds ratio 1.01; 95% CI 1.01 to 1.02), higher overall morbidity (odds ratio 1.07; 95% CI 1.05 to 1.09), and major morbidity (odds ratio 1.06; 95% CI 1.04 to 1.08) compared with directly admitted patients., Conclusions: After rigorous risk adjustment, interhospital transfer status has a small effect on mortality and morbidity in the EGS population. This could suggest that it is reasonable to transfer patients and that regionalization of care should be encouraged., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown., Methods: We performed an analysis of the Florida State Inpatient Database (2010-2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived., Results: Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes., Conclusions: Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: The objective of our study was to characterize providers' impressions of factors contributing to disproportionate rates of morbidity and mortality in emergency general surgery to identify targets for care quality improvement., Background: Emergency general surgery is characterized by a high-cost burden and disproportionate morbidity and mortality. Factors contributing to these observed disparities are not comprehensively understood and targets for quality improvement have not been formally developed., Methods: Using a grounded theory approach, emergency general surgery providers were recruited through purposive-criterion-based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to emergency general surgery outcomes, to define effective care for EGS patients, and to describe operating room team structure. Interviews were performed to thematic saturation. Transcripts were iteratively coded and analyzed within and across cases to identify emergent themes. Member checking was performed to establish credibility of the findings., Results: A total of 40 participants from 5 academic hospitals participated in either individual interviews (n = 25 [9 anesthesia, 12 surgery, 4 nursing]) or focus groups (n = 2 [15 nursing]). Emergency general surgery was characterized by an exceptionally high level of variability, which can be subcategorized as patient-variability (acute physiology and comorbidities) and system-variability (operating room resources and workforce). Multidisciplinary communication is identified as a modifier to variability in emergency general surgery; however, nursing is often left out of early communication exchanges., Conclusion: Critical variability in emergency general surgery may impact outcomes. Patient-variability and system-variability, with focus on multidisciplinary communication, represent potential domains for quality improvement in this field., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission., Methods: : We performed a cross-sectional descriptive analysis using data on ED visits from 2006-2011 to determine change in admission and surgical patterns over time. The Nationwide Emergency Department Sample database, a nationally representative administrative claims dataset, was used to analyze ED visits for diverticulitis. We included patients with a principal diagnosis of diverticulitis (ICD-9 codes 562.11, 562.13). We analyzed the rate of admission and surgery in all admitted patients and in low-risk patients, defined as age <50 with no comorbidities (Elixhauser). We used hierarchical multivariate logistic regression to identify patient characteristics associated with admission for diverticulitis., Results: Fryom 2006 to 2011 ED visits for diverticulitis increased by 21.3% from 238,248 to 302,612, while the admission rate decreased from 55.7% to 48.5% (-7.2%, 95% CI [-7.78 to -6.62]; p<0.001 for trend). The admission rate among low-risk patients decreased from 35.2% in 2006 to 26.8% in 2011 (-8.4%, 95% CI [-9.6 to -7.2]; p<0.001 for trend). Admission for diverticulitis was independently associated with male gender, comorbid illnesses, higher income and commercial health insurance. The surgical rate decreased from 6.5% in 2006 to 4.7% in 2011 (-1.8%, 95% CI [-2.1 to -1.5]; p<0.001 for trend), and among low-risk patients decreased from 4.0% to 2.2% (-1.8%, 95% CI [-4.5 to -1.7]; p<0.001 for trend)., Conclusion: From 2006 to 2011 ED visits for diverticulitis increased, while ED admission rates and surgical rates declined, with comorbidity, sociodemographic factors predicting hospitalization. Future work should focus on determining if these differences reflect increased disease prevalence, increased diagnosis, or changes in management.