Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.
February 1, 2022
Ross SW, Reinke CE, Ingraham AM, et al. Emergency general surgery quality improvement: A review of recommended structure and key issues. J Am Coll Surg. [In press 2022.]
Davis KA. Providing high-quality care for emergency general surgery patients. J Am Coll Surg. [In press 2022.]
Ross and colleagues described the basic structural components of quality improvement (QI) initiatives for emergency general surgery (EGS) programs. The authors noted that EGS patients represent 11% of annual hospital admissions in the US and more than 50% of postoperative deaths. QI efforts target areas such as registry design and implementation, creation of evidence-based protocols and standards, organization of regional collaboratives, development and testing of interventions for special populations such as geriatric patients and targeting of recognized causes of mortality and morbidity, including failure to rescue. Data presented in the article confirmed that failure to rescue is a persistent problem for EGS patients and an area in which little progress has been made.
A recent important initiative is the organization of an ACS verification program for EGS centers. The article stressed the importance of including data such as severity scoring using indices like the AAST (American Association for the Surgery of Trauma) universal grading system, documenting the physiologic status of the patient, recording comorbid conditions, and documenting both short- and long-term outcomes. Use of tested care bundles such as the Emergency Laparotomy Pathway Quality Improvement bundle from the National Emergency Laparotomy Audit was recommended. A useful illustration of the elements of this bundle is included in the article.
In the editorial that accompanied the article, Davis noted that creation of a dedicated national EGS QI program will be a complex task requiring consistent dedication of participants and support by surgeons, hospitals, and professional organizations.
Slakey DP, Sargut G, Glowacki NE. Using flow process disruption analysis to guide quality improvement. J Am Coll Surg. [In press 2022.]
In this report of a paper presented at the 2021 annual meeting of the Southern Surgical Association, Douglas P. Slakey, MD, FACS, and coauthors described a QI initiative conducted in a single, 900-bed teaching hospital using process flow disruption analysis. Surgical processes were analyzed over a 4-month interval and identified flow disruptions were used to guide QI initiatives.
One disruption identified was difficulty in obtaining a reversal agent for intraoperative paralysis in a timely fashion. Correction of this disruption resulted in a 59% reduction in postoperative respiratory failure and a direct cost savings of nearly $500,000 in the first year following implementation of the QI program. The authors concluded that emphasis on resolving flow disruptions can lead to QI programs that improve reliability, increase patient safety, and reduce costs.
Rosen MJ, Krpata DM, Petro CC, et al. Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial. JAMA Surg. January 19, 2022 [Epub ahead of print].
Stolarski AE, Itani KMF. Nailing the Coffin on Biological Mesh in Contaminated Ventral Hernias. JAMA Surg. January 19, 2022 [Epub ahead of print].
Rosen and colleagues reported results of a single-blinded randomized prospective trial that compared hernia recurrence rates and other outcomes in patients who had contaminated ventral hernias repaired with either biologic or synthetic mesh reinforcement. The trial included 253 patients and was conducted over a 7-year interval; 2-year follow up data were available for 92% of patients. Mesh was placed in a retro-muscular position at the time of fascial closure.
Risk of hernia recurrence was significantly higher in patients who had biologic mesh placed at the time of hernia repair. Rates of surgical site recurrence requiring intervention were equivalent in both patient groups. Hospital costs were nearly $45,000 per patient for biologic mesh placement compared with $17,000 for patients who had synthetic mesh placement. The authors concluded that synthetic mesh was preferred because of lower risk of hernia recurrence and lower cost with no differences noted in safety profiles.
In the accompanying editorial, authors noted that all surgeon participants in the trial were experts in hernia repair, which may limit the applicability of the data to real-world settings. Nonetheless this potential drawback, these data should serve to make surgeons more comfortable using polypropylene mesh for hernia repairs in patients with potentially contaminated wounds.