Emergency and trauma surgeries are increasingly being performed by the same providers, often using the same resources. It has been implied that improvements in care for one of these populations could enhance the care of the other, but few analyses have compared the quality of care provided to each type of surgery group.
In the Archives of Surgery, my colleagues and I had a study published that evaluated the relationship between trauma and elective general surgery (ELGS) and emergency general surgery (EMGS) care. Our hypothesis was that there would be similarities in mortality and serious morbidity outcomes because of the crossover in providers and resources used. We compared performance among 46 hospitals to determine how well these institutions performed across populations with regard to outcomes.
Our findings indicated that there were no significant relationships between trauma and EMGS mortality or between trauma and ELGS mortality. We also didn’t observe any significant relationships between trauma and EMGS morbidity or between trauma and ELGS morbidity. Furthermore, no hospital had consistently good or poor outcomes across the surgical populations assessed in the analysis.
Based on our findings, research and quality improvement efforts should focus on how to improve EMGS care. Many performance improvement measures have been devoted to trauma surgery, but few have focused on EMGS patients. The National Trauma Databank contains records on more than 2 million patients. The American College of Surgeons has established the Trauma Quality Improvement Program for benchmarking trauma centers. Similar data banks and benchmarking efforts that focus on quality of care provided to EMGS patients are in the early stages of development and implementation.
As another example, a well-defined system is in place to direct the triaging of trauma patients and transfers to higher levels of care. A similar structure for referrals to a tertiary care facility does not exist for EMGS patients. Acute care surgery services—which provide care to both trauma surgery and EMGS—are relatively new. As such, EMGS patients have not yet derived the benefits of existing trauma performance improvement initiatives. We can optimize the care we provide to EMGS patients as performance improvement efforts for these individuals gain more attention and funding.
If the commitment and resources currently devoted to improving trauma performance continue to be carried over into EMGS patients through acute care surgery services, it may only be a matter of time before the quality of EMGS care matches that of trauma surgery. At hospitals where acute care surgery services are not feasible, the combination of resources for EMGS quality improvement efforts and those for trauma performance improvement initiatives should be explored.
Readings & Resources (click to view)
Ingraham A, Hasa B, Cohen M, et al. Comparison of hospital performance in trauma vs emergency and elective general surgery: implications for acute care surgery quality improvement. Arch Surg. 2012;147:591-598. Available online at http://archsurg.jamanetwork.com/article.aspx?articleid=1150147.
Shafi S, Parks J, Ahn C, et al. Centers for Medicare and Medicaid services quality indicators do not correlate with risk-adjusted mortality at trauma centers. J Trauma. 2010;68:771-777.
Hemmila M, Nathens A, Shafi S, et al. The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility. J Trauma. 2010;68:253-262.
Glance L, Osler T, Mukamel D, et al. Impact of statistical approaches for handling missing data on trauma center quality. Ann Surg. 2009;249:143-148.
Hall B, Hamilton B, Richards K, et al. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250:363-376.
Huseynova K, Xiong W, Ray J, et al. Venous thromboembolism as a marker of quality of care in trauma. J Am Coll Surg. 2009;208:547-552.
Ingraham A, Cohen M, Bilimoria K, et al. Association of surgical care improvement project infection-related process measure compliance with risk-adjusted outcomes: implications for quality measurement. J Am Coll Surg. 2010;211:705-714.