Michigan Acute Care Surgery CQI
MSQC/ASPIRE Collaborative Meeting
Virtual, MI
April 23, 2021
Acute Care Surgery
• Inadequate on-call coverage (2005, ACEP)
• Surgical society response - AAST
• Acute care surgery
– Trauma
– Surgical Critical Care
– Emergent General Surgery
• Fellowship (2008)
• Model of care at many hospitals
Acute Care Surgery – Economic Footprint
• National Inpatient Sample
• ICD-9
– Trauma
– 16 Emergent General Surgery Conditions
• 29 million patients
– 20% ACS diagnosis
– 25% of US inpatient costs
– $85 Billion
Acute Care Surgery – Economic Footprint
• National Inpatient Sample
• ICD-9
– Trauma
– 16 Emergent General Surgery Conditions
• 29 million patients
– 20% ACS diagnosis
– 25% of US inpatient costs
– $85 Billion
Takeaway
• Prevalence - high
• Expense - high
• Problems - many
• Small iterative savings/improvements have
potential for large impact overall
MACS
• July 2019
– Beaumont Dearborn > Sparrow Hospital (2020)
– St. Joseph Mercy Ann Arbor
– Spectrum Health
– Michigan Medicine
• Data capture
– Qualtrics
• Expansion
– 2021 (DRH/Harper, Metro Health, McLaren Macomb, Borgess)
– 2022 (4 more hospitals to total of 12)
Overview of Data Capture
Diseases
Acute Appendicitis
Acute Gallbladder disease
Cholecystitis
Choledocholithiasis/Cholangitis
Gallstone pancreatitis
SBO
Hernia (if present)
Emergent Exploratory Laparotomy
Operative and non-operative cases
Overview of Data Capture
Non-operative
Operative
Readmission
Index admit, collapse readmits to index
Finding patients
Census (ACS service?)
Consults
Admits
Operations
Capture
Demographics
Comorbid Conditions
Disease
Operation(s)
Studies
IR
Outcomes
Disposition
Reports
Summary
Acute Appendicitis
Acute Gallbladder Disease
Small Bowel Obstruction
Hernia if present
Emergent Exploratory Laparotomy
Total Patients = 6,939
967
SJ
2992
SH
461
OW
2068
UM
442
SP
9
MH
CPT – Operation, 15 most frequent
N %
47562, Laparoscopic cholecystectomy 1456 25.6
44970, Laparoscopic appendectomy 1013 17.8
44120, Resection of small intestine 171 3.0
44005, Freeing of bowel adhesion 133 2.3
47563, Lap cholecystectomy w IOC 113 2.0
47600, Open cholecystectomy 102 1.8
44160, Partial colectomy w TI 51 0.9
44143, Partial colectomy w colostomy 49 0.9
44140, Partial colectomy w anast 47 0.8
49561, Repair ventral/inc hernia 44 0.8
43840, Gastrorrhaphy, Graham patch 40 0.7
44950, Open appendectomy 31 0.5
49000, Exploration of abdomen 31 0.5
49587, Repair umbilical hernia 25 0.4
44050, Reduction volvulus, intussusception 24 0.4
All other 2361 41.5
Operative Intervention
Appendicitis Gallbladder SBO
0
50
100
Operation
Disease
%
OW
SH
SJ
SP
UM
Acute Appendicitis
Appendicitis Uncomplicated Complicated
0
50
100
Operation
Appendicitis Type
%
OW
SH
SJ
SP
UM
Emergent Exploratory Laparotomy
OW SH SJ SP UM
0
10
20
30
40
Transfer In
Hospital
%
OSH ED
OSH
Emergent Exp. Laparotomy
433 Patients since May
Point of Entry
Home: 1.4%
ED: 61%
OSH ED Transfer: 21%
OSH Transfer: 6.2%
ED Only, no admit: 10%
N %
Perforation 117 27.0
Colon 80 18.5
Small bowel 2 0.5
Stomach/Duodenum 35 8.1
Obstruction 184 42.5
Hernia 57 13.2
Malignancy 17 3.9
Other (Volvulous, Intussusception) 110 25.4
Ischemia 34 7.9
Other 53 12.2
Emergency Ex. Lap – Outcomes
N %
Any Complication 256 59.1
Incisional SSI 22 5.1
Organ space SSI 46 10.6
Sepsis or severe sepsis 86 19.9
Anastomotic leak 9 2.1
Wound disruption 5 1.2
Enterocutaneous fistula 3 0.7
Ileus 48 11.1
C. difficle colitis 11 2.5
VTE 9 2.1
Pneumonia 37 8.5
Cardiac arrest 17 3.9
Post-discharge ED visit 52 12.0
Readmission 71 16.4
Mortality 72 16.6
NEWS2 Score
National Early Warning Score
Royal College of Physicians
England NHS
December 2017 update → NEWS2
Why? NEWS was founded on the premise that
(i) early detection,
(ii) timeliness and,
(iii) competency of the clinical response comprise a
triad of determinants of clinical outcome in people
with acute illness.
NEWS2 Score
National Emergency Laparotomy Audit (NELA)
Use NEWS2 for detection
RR, O2, Temp, SBP, HR, Consciousness
Score
Range 0-20
Clinical Risk for Deterioration
Low: 0-4 10.9%
Medium: 5-6 67.4%
High: ≥7 21.7%
Care Bundle - ELPQuiC
Identification
Timely consult (Surgeon)
Timely antibiotics
Prompt diagnosis (CT scan)
Goal directed resuscitation
Early operation (6 hrs from decision to operate)
ICU care
SBO - Gastrografin
Prior SBO
SBO - Gastrografin
No Prior SBO
↑
↑
Panel Discussion
• John LaGorio, MD - Mercy Health Muskegon
• Lena Napolitano, MD - Michigan Medicine
• Wayne VanderKolk, MD - Mercy Health St. Mary’s
Panel Questions
1. What diseases/operations would you
most like information on with regard to
emergent general surgery?
Panel Questions
2. Where do you see variability in how
surgeons treat emergent general surgery
patients?
a. Selection of operative vs. non-operative
b. Peri-op optimization
c. Who to transfer, where, and when
Panel Questions
3. What happens to patients whom get a
cholecystostomy tube for acute
cholecystitis?
Panel Questions
4. Should surgeons offer patients non-
operative treatment for acute appendicitis?
Panel Questions
4. Should surgeons offer patients non-
operative treatment for acute appendicitis?
a. Age considerations
b. Follow up considerations
Panel Questions
5. How should peri-operative resuscitation
be performed? What are your resuscitation
parameter endpoints or metrics? Are there
specific anesthesia concerns that must be
addressed in emergent/urgent EGS
patients?
Panel Questions
6. Who provides critical care for your EGS
patients?
Panel Questions
7. Operative techniques
a. How do you do a small bowel
anastomosis in EGS patients?
b. How do you do a colon anastomosis
in EGS patients?
c. Who should have the abdomen left
open temporarily? Any tips?
d. What patients do you divert with a
colostomy or ileostomy?
Panel Questions
8. The concept of zero preventable deaths
has been applied to trauma, does it apply to
EGS?
a. What or who is an appropriate patient
to offer operative intervention to?
b. How should the data be captured for
withdrawal of care and/or patients in
whom operative intervention was or
would be likely futile?
Panel Questions
9. Emergent exploratory laparotomy
interventions
a. Do these patients merit a dedicated
OR team (Anesthesia, nursing, eg
transplant or cardiac)?
b. Should there be a clinical decision
support tool for choosing or not
choosing a staged operative course?
Questions
