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Emergency Surgery Needs Distinct Code Registry, Researchers Say

 |  By cclark@healthleadersmedia.com  
   February 08, 2012

Surgery is surgery, right?  Hernias and intestinal repairs? Gall bladders and appendectomies?  Whether they're prompted by a 911 call or scheduled a week in advance?

No, not anymore. Or at least they shouldn't be. In fact, the quality and outcomes of these procedures depend enormously on whether the patient's medical issue is rushed to the operating room emergently, or is done with a scheduled elective appointment.

That's the view of a group of surgical researchers at Wake Forest University Medical Center, who say that although these two entry points involve dramatically different variables and risk equations, hospitals generally lump all of a general surgeon's operative patients together when judging quality.

When hospital quality chiefs review surgeon mishaps, say in morbidity and mortality reports each month, factors that influenced the outcome both within and outside of the provider's control are not studied as a group.

In fact, emergency surgery oversight might work better if it operated a lot more like how the national and regional trauma systems function today, with their own separate patient registries, they suggest. Members of this Wake Forest group have developed just such a registry to prove their point.

"The more we look at emergency general surgery,... it looks like this  condition or problem is a lot more than just what anatomical problem need to be fixed; these are very different populations," says study author Preston Miller, MD, a surgeon and Wake Forest associate professor in Winston-Salem. "Those patients behave a lot differently than the patients who have the same operations on an elective basis."

Miller, a trauma and acute care surgeon, says he "brings the eyes of trauma to this topic, and it seems like a natural fit."

In an article this week in the Journal of the American College of Surgeons, Miller and colleagues suggest that medical centers throughout the country start looking at outcomes of emergency surgeries as their own category, separate from scheduled surgeries. The idea is that emergency surgery patients that are not trauma patients (victims of violence or unintentional injuries) should be categorized with their own ICD-9 code registry.

"Trauma is easy, because a) everyone knows what trauma is; it falls into a certain set of ICD-9 codes," Miller says.

"That's not true with emergency surgery, where the codes are all over the map.  One of the things we hope to do with the development of this registry is propose, and then test a system to define what [codes constitute] emergency general surgery, and then begin to track those codes."

Take for example, diverticulitis. Patients get the same operation whether they have a complex perforation that causes them to become systemically ill with infection or have a less severe case. The procedure is the same regardless of whether their surgery is delayed or postponed, or whether it's done right away.

Yet all these variables can affect the outcome. The skill of the surgeon can also play a role.

"There's a general feeling that a person will do worse if they require an emergent operation, but there's not a detailed understanding from a research standpoint how much worse," Miller explains. "What particular factors make them do worse, and (for those who do better), what is it about our system that is working?"

Miller emphasizes that the American College of Surgeons has not endorsed his group's registry concept, nor has the National Quality Forum.  But within a year, he thinks there will be enough patients loaded into the database that some clear trends will emerge.  And they will help his organization see what surgeons and other members of the emergency care team are doing right, and what they might improve.

Down the line, hospitals could look at emergency surgery versus elective surgery for the same procedures on a county or regional or even a statewide basis to get a sense of what influences the best outcomes.

Currently, the most common diagnoses identified include intestinal obstruction, hernia repair, peritonitis, diverticulitis, peptic ulcer disease, and appendicitis.

The need for such a database becomes all the more important as surgeons gravitate to hospital employment, rather than remain independent practitioners who operate on emergency patients only when they are on call, Miller agrees.

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