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Emergency general surgery (EGS) admissions account for more than 3 million hospitalizations in the US annually. We aim to better understand characteristics and mortality risk for EGS interhospital transfer patients compared to EGS direct admissions. Using the 2002–2011 Nationwide Inpatient Sample we identified patients aged ≥18 years with an EGS admission. Patient demographics, hospitalization characteristics, rates of operation and mortality were compared between patients with interhospital transfer versus direct admissions. Interhospital transfers comprised 2% of EGS admissions. Interhospital transfers were more likely to be white, male, Medicare insured, and had higher rates of comorbidities. Interhospital transfers underwent more procedures/surgeries and had a higher mortality rate. Mortality remained elevated after controlling for patient characteristics. Interhospital transfers are at higher risk of mortality and undergo procedures/surgeries more frequently than direct admissions. Identification of contributing factors to this increased mortality may identify opportunities for decreasing mortality rate in EGS transfers. •EGS interhospital transfers have higher rates of mortality than direct admissions.•Direct admissions are less likely to have a procedure or surgery than transfers.•Odds of mortality remain elevated despite controlling for patient characteristics.

Health literacy is “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions,” as defined by the Patient Protection and Affordable Care Act of 2010.1 Health literacy can include a variety of skills, including understanding prescription labels on medications, reading and appropriately filling out medical forms in doctors’ offices, and actively participating in the informed consent process for medical and surgical procedures. In their manuscript, Dr. Baker and colleagues evaluate the relationship between health literacy and surgical outcomes, namely emergency department visits and hospital readmissions.2 This work is timely, as these outcomes are costly to both patients and hospital systems and have gained the attention of various healthcare stakeholders nationwide, especially after the implementation of the Affordable Care Act’s Hospital Readmissions Reduction Program in 2010.3,4 In a population of Veterans Affairs patients across four sites, low health literacy was associated with increased rates of readmission and post-discharge complications, but there was no difference in length of stay or emergency department visits. There are multiple tools used to measure health literacy, and the authors here used the 3-question Brief Health Literacy Screen.6 This tool asks patients about their confidence in filling out medical forms, their frequency of needing assistance with reading hospital materials, and their frequency of having problems learning about their medical conditions because of difficulties with understanding written materials.7 The benefit of this instrument is that it is not time-consuming and can be practically and broadly implemented in a surgical practice.

Management of incarcerated hernias is a common issue facing general surgeons across the USA. When hernias are not able to be reduced, surgeons must make decisions in a short time frame with limited options for patient optimization. In this article, we review assessment and management options for incarcerated ventral and inguinal hernias.

As electronic discharge summaries (EDS) become more prevalent and health care systems increase their focus on transitions of care, analysis of EDS quality is important. The objective of this study was to assess the timeliness and quality of EDS compared with dictated summaries for surgical patients, which has not previously been evaluated. A retrospective study was conducted of a sample of discharge summaries from surgical patients at an urban university teaching hospital before and after the implementation of an EDS program. Summaries were evaluated on several dimensions, including time to summary completion, summary length, and summary quality, which was measured on a 13-item scoring tool. After the exclusion of 5 patients who died, 195 discharge summaries were evaluated. Discharge summaries before and after EDS implementation were similar in admission types and discharge destinations of the patients. Compared with dictated summaries, EDS had equivalent overall quality (P = .11), with higher or equivalent scores on all specific quality aspects except readability. There was a highly significant statistical and clinical improvement in timeliness for electronic summaries (P < .01). Obvious use of copying and pasting was identified in 8% of discharge summaries and was associated with decreased readability (P = .02). The implementation of EDS can improve the timeliness of summary completion without sacrificing quality for surgical patients. Excessive copying and pasting can reduce the readability of discharge summaries, and strategies to discourage this practice without the use of appropriate editing should be used.

Variation in cost of surgical care across state lines is poorly understood. We sought to examine state-level variation in wage-adjusted total cost (WATC) of a common surgical procedure. We performed a retrospective cohort study of patients undergoing total thyroidectomy in the Nationwide Inpatient Sample (2007 to 2008). WATC was calculated from charges and adjusted for the area wage index. Hierarchical linear modeling was used to investigate the variation in WATC explained by variables at the patient, hospital, and state levels. We identified 11,058 eligible patients from 35 states. The overall mean WATC was $8,132; 37% of the WATC variance was because of differences across hospitals, whereas 28% was explained by patient-level factors and 8% because of differences across states. More than a quarter of the variation in cost of total thyroidectomy was not explained by patient-, hospital-, or state-level factors. Further research is needed to understand the unexplained residual variation. •We calculated adjusted total cost for total thyroidectomy across the United States.•The mean cost varied substantially between states.•After adjustment, 27% of the variation in cost remained unexplained.•Only 28% of the variation in cost was explained by patient factors.

Smoking is associated with increased postoperative complications. Pre-surgical smoking cessation remains a challenge. Our aim was to summarize pre-hospital smoking cessation interventions and impact on smoking cessation rates. Independent review of English language articles identified from systematic searches of MEDLINE, PubMed, PsycInfo, Embase, Web of Science, and Cumulative Index to Nursing & Allied Health Literature databases from 1998 to 2019 was performed (PROSPERO registration number CRD42021247927). Studies of adult patients enrolled in a pre-hospital smoking cessation intervention were included. Studies with historical controls or only self-reported outcomes were excluded. Nine articles including 1762 patients were identified. Exhaled CO was used to confirm cessation. Six studies reported smoking status day of surgery. Interventions included NRT, hand-held technology, e-cigarettes, decision aids/counseling and medications. Four studies demonstrated a difference in smoking cessation rates. Ethics and study appraisal were assessed using ROB2. Based on the variability of interventions, settings, and outcomes, best practice for successful pre-hospital smoking cessation in surgery clinics would benefit from ongoing investigation. [Display omitted] •A review of the literature shows that it is undetermined whether intervention influences preoperative smoking cessation.•Among articles that show improved smoking cessation, there is no common intervention between them.•Great need exists for ongoing investigation regarding successful preoperative smoking cessation interventions.

BackgroundFreestanding emergency departments (FSEDs) have generated improved hospital metrics, including decreased ED wait times and increased patient selection. Patient outcomes and process safety have not been evaluated. This study investigates the safety of FSED virtual triage in the emergency general surgery (EGS) patient population.Methods and proceduresA retrospective review evaluated all adult EGS patients admitted to a community hospital between January 2016 and December 2021 who either presented at a FSED and received virtual evaluation from a surgical team (fEGS) or presented at the community hospital emergency department and received in-person evaluation from the same surgical group (cEGS). Patients’ demographics, acute care utilization history, and clinical characteristics at the onset of the index visit were used to build a propensity score model and stabilized Inverse Probability of Treatment Weights (IPTW) were used to create a weighted sample. Multivariable regression models were then employed to the weighted sample to evaluate the treatment effect of virtual triage compared to in-person evaluation on short-term outcomes, including length of stay (LOS) and 30-day readmission and mortality. Variables which occurred during the index visit (such as surgery duration and type of surgery) were adjusted for in the multivariable analyses.ResultsOf 1962 patients, 631 (32.2%) were initially evaluated virtually (fEGS) and 1331 (67.8%) underwent an in-person evaluation (cEGS). Baseline characteristics demonstrated significant differences between the cohorts in gender, race, payer status, BMI, and CCI score. Baseline risks were well balanced in the IPTW-weighted sample (SD range 0.002–0.18). Multivariable analysis found no significant differences between the balanced cohorts in 30-day readmission, 30-day mortality, and LOS (p > 0.05 for all).ConclusionPatients who undergo virtual triage have similar outcomes to those who undergo in-person triage for EGS diagnoses. Virtual triage at FSED for these EGS patients may be an efficient and safe means for initial evaluation.

BackgroundThe majority of laparoscopic paraesophageal hernia (PEH) repairs are performed electively. We aimed to investigate the frequency of non-elective laparoscopic (MIS) PEH repair and compare 30-day outcomes to elective MIS repairs and non-elective open repairs. We hypothesized that an increasing percentage of non-elective PEH repairs would be performed laparoscopically and that this population would have improved outcomes compared to non-elective open PEH counterparts.MethodsThe 2011–2016 NSQIP PUFs were used to identify patients who underwent PEH repair. Case status was classified as open vs. MIS and elective versus non-elective. Preoperative patient characteristics, operative details, discharge destination, and 30-day postoperative complication rates were compared. Logistic regression was used to examine the impact of case status on 30-day mortality.ResultsWe identified 20,010 patients who underwent PEH. There were an increasing number of MIS PEH repairs in NSQIP between 2011 and 2016. Non-elective repairs were performed in 2,173 patients and 73.4% of these were completed laparoscopically. Elective MIS patients were younger, had a higher BMI, and were more likely to be functionally independent (p < 0.01) than their non-elective counterparts. Non-elective MIS patients had a higher wound class and ASA class compared to their elective counterparts. Compared to elective MIS cases, non-elective MIS PEH repair was associated with increased odds of mortality, even after controlling for patient characteristics (OR = 1.76, p = 0.02). There was no statistically significant difference in mortality for non-elective MIS vs. non-elective open PEH repair. There is an increase in non-elective PEH repairs recorded in NSQIP over time studied.ConclusionsThe population undergoing non-elective MIS PEH repairs is different from their elective MIS counterparts and experience a higher postoperative mortality rate. While the observed increased utilization of MIS techniques in non-elective PEH repairs likely provides benefits for the patient, there remain differences in outcomes for these patients compared to elective PEH repairs.

Surgical follow-up allows patients to discuss pathology and preventative maintenance. Multiple factors impact patients’ compliance with surgical follow-up. We hypothesized that increased travel time would be associated with lack of post-discharge surgical follow-up. Retrospective analysis identified patients undergoing laparoscopic appendectomy or laparoscopic cholecystectomy. Descriptive statistics and logistic regression assessed the relationship between patient characteristics and post-discharge follow-up. We identified 1830 patients from 2015–2016. 31% did not complete follow-up, were more likely to have had an appendectomy, be un- or underinsured, not married, and live outside North Carolina. Median round-trip travel time was not significantly different. After adjustment for patient factors, each additional 10 min of travel time increased the odds of not following up by 6% (p < 0.01). Travel time was the only modifiable factor associated with post-discharge follow-up. Novel methods of completing follow-up that minimize travel time, such as virtual visits, may increase compliance with recommended follow-up. •Of 1830 patients, 69% completed 60-day post-discharge surgical follow-up.•Patients age 19–44, single, and under- or uninsured have lower rates of follow-up.•Longer travel time is associated with lack of follow-up.

BackgroundMinimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade.MethodsThe 2007–2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis.ResultsDuring the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p < 0.001). There was a concurrent decrease in mean days of hospitalization in each group: appendectomy (2.4 to 2.0), cholecystectomy (5.7 to 3.2), peptic ulcer disease (20.3 to 11.7), and bowel obstruction (12.9 to 10.5); p < 0.001 for all. On multivariate analysis, use of MIS techniques was associated with decreased odds of 30-day mortality, surgical site infection, and length of hospital stay in all groups (p < 0.001).ConclusionsUse of MIS techniques in these four EGS diagnoses has increased in frequency over the past 10 years. When adjusted for preoperative risk factors, use of MIS was associated with decreased odds of wound infection, death, and length of stay. Further studies are needed to determine if increased access to MIS techniques among EGS patients may improve outcomes.