Research Article: Past, present, and future of Emergency General Surgery in the USA

Date Published: January 12, 2018

Publisher: John Wiley and Sons Inc.

Author(s): Heather G. Lyu, Peter Najjar, Joaquim M. Havens.


Emergency General Surgery (EGS) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS. Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.

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The earliest national initiative to standardize modern surgical trauma and emergent surgical care in the USA was born out of the military experience in the Korean and Vietnam wars. Injured soldiers were stabilized in forward surgical units and transferred to regional centers based on the acuity of their injuries. The effectiveness of this approach led to the creation of an accreditation system for trauma centers in the USA based on a hospitals’ facilities and treatment capabilities.1 The American College of Surgeons Committee on Trauma (ACS‐COT) formed and pioneered regionalization of trauma centers in the 1950s. By 1987, ACS‐COT served as a verification program for trauma hospitals. This eventually led to the development of the Verification and Review Committee and Performance Improvement/Patient Safety programs to promote compliance to ACS guidelines for trauma and general surgery centers and to collect data on performance metrics.2 Trauma has become well recognized as a widespread public health problem and since the 1970s, it has become a focus of quality improvement, particularly with the creation and advancement of a comprehensive, standardized trauma registry, the National Trauma Data Bank (NTDB).3, 4 Many publications influencing interventions and guidelines based on NTDB investigations have been generated since its inception.5 However, non‐trauma surgical emergencies remained unrecognized as a public health concern at that time.

As EGS continues to mature as a surgical specialty, accounting for an estimated $28 billion in annual hospital costs in the USA, there has been a significant emphasis on data collection, quality, and performance measurement, and the development of evidence‐based guidelines and protocols.11 Since 2013, there have been further attempts to define the scope of emergency general surgery. A follow‐up study proposed 149 ICD‐9 procedure codes that could or would treat any of the previously defined 621 ICD‐9 diagnosis codes.8 In 2016, a study querying the National Inpatient Sample defined 7 procedure groups accounting for approximately 80% of the operative EGS burden throughout the USA.12 The findings allow for the development of EGS quality benchmarks that can be used to improve evidence‐based guidelines and create clinical decision support systems.

Currently, most of the EGS outcomes research in the USA has been undertaken using administrative datasets, such as the National Inpatient Sample, as well as state inpatient databases. Although these databases capture many EGS cases, they do not include prospectively collected clinical data. The lack of clinical information in these databases limits the ability to appropriately risk‐adjust for the widely variable EGS patient population. An EGS registry modelled after the NSQIP and the NTDB was created in 2012 at Wake Forest University (Winston‐Salem, NC, USA) and is being studied by the ACS.17 The development of a robust national EGS registry will allow researchers and surgeons to undertake large, risk‐adjusted studies to create EGS‐specific benchmarks and risk stratification systems.

Approval of the research protocol: N/A.




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