A. Columbus1, E. Lilley1, A. Harlow1, M. Morris2, A. Haider1,3, A. Salim1,3, J. Havens1,3 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2University Of Colorado Denver,Aurora, CO, USA 3Brigham And Women’s Hospital,Division Of Trauma, Burn, And Surgical Critical Care,Boston, MA, USA
Introduction: Emergency General Surgery (EGS) patients are up to 8 times more likely to die than patients undergoing the same procedure electively. One half of all EGS patients will have a major complication. Despite these burdens, few studies have identified modifiable factors that influence patient outcomes in EGS. Our purpose in this work was to identify modifiable factors linked to morbidity and mortality in EGS as perceived by EGS providers.
Methods: EGS providers, including anesthesiologists, nurses, and surgeons, from the four US census regions were recruited via purposive-stratified criterion based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to EGS outcomes, to define effective care for EGS patients, and to describe operating room (OR) team structure. Interviews were performed to thematic saturation. All data were audio-recorded and transcribed verbatim. Using a grounded theory approach, three members of our research team inductively coded all transcripts. Coded data were entered into Atlas.ti for data management and were analyzed within and across cases to identify emergent themes.
Results: A total of 40 participants from 5 academic hospitals were interviewed either individually (n = 25 {9 anesthesia, 12 surgery, 4 nursing}) or within focus groups (n = 2 {15 nursing}). The impact of variability on EGS outcomes emerged as a major theme, with two subthemes: patient variability (acute physiology and comorbidities) and system variability (OR space and workforce). Participants from fixed staffing model institutions, characterized by dedicated EGS OR space and staffing, focused on patient variability as the primary contributor to negative EGS outcomes while participants from non-fixed staffing institutions cited disruption in case flow due to system variability as a major contributor.
Conclusion: EGS providers report patient and system variability as key contributors to poor EGS outcomes. While EGS patient variability is not directly modifiable, variability due to system-based factors, including OR space and staffing of EGS care teams, is the product of differences in hospital systems and therefore is modifiable. These data support the use of a fixed staffing model for EGS. Further investigation into the effect of staffing models on EGS outcomes is needed.
