Can the emergency surgery score (ESS) be used as a triage tool predicting the postoperative need for an ICU admission?

Napaporn Kongkaewpaisan; Jae Moo Lee; Ahmed I Eid; Manasnun Kongwibulwut; Kelsey Han; David King; Noelle Saillant; April E Mendoza; George Velmahos; Haytham M A Kaafarani

doi:10.1016/j.amjsurg.2018.08.002

Can the emergency surgery score (ESS) be used as a triage tool predicting the postoperative need for an ICU admission?

Am J Surg. 2019 Jan;217(1):24-28. doi: 10.1016/j.amjsurg.2018.08.002. Epub 2018 Aug 23.

Authors

Affiliations

¹ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA; Division of Acute Care and Ambulatory Surgery, Siriraj Hospital, Mahidol University, 2, Wanglang Rd, Sayammin Building 12th Floor, Department of Surgery, Bangkoknoi, Bangkok, 10700, Thailand. Electronic address: NKONGKAEWPAISAN@mgh.harvard.edu.
² Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: JLEE187@PARTNERS.ORG.
³ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: AEID@mgh.harvard.edu.
⁴ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: mkongwibulwut@mgh.harvard.edu.
⁵ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: KRHAN@mgh.harvard.edu.
⁶ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: DKING3@mgh.harvard.edu.
⁷ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: NSAILLANT@PARTNERS.ORG.
⁸ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: AEMENDOZA@mgh.harvard.edu.
⁹ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: GVELMAHOS@mgh.harvard.edu.
¹⁰ Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. Electronic address: HKAAFARANI@mgh.harvard.edu.

PMID: 30172358
DOI: 10.1016/j.amjsurg.2018.08.002

Abstract

Background: The emergency surgery score (ESS) is a preoperative risk calculator recently validated as a mortality predictor in emergency surgery (ES) patients. We sought to evaluate the utility of ESS as an ICU admission triage tool.

Methods: A four-step methodology was designed. First, the 2007-2015 ACS-NSQIP database was examined to identify all ES patients using the "emergent" variable and CPT codes for "digestive system". Second, we created a composite variable called ICUneed, defined as death or the development of one or more postoperative complication warranting critical care (e.g. unplanned intubation, ventilator dependent ≥48 h, cardiac arrest, septic shock and coma ≥24 h). Third, for each patient, ESS was calculated. Fourth, the correlation between ESS and ICUneed was assessed by calculating the model c-statistics (AUROC).

Results: Out of a total of 4,456,809 patients, 65,989 patients were included. The mean population age was 56 years; 51% were female, and 71% were white. The overall 30-day postoperative mortality and morbidity were 8.2% and 31.7%, respectively. ESS gradually and accurately predicted ICUneed, with 1%, 40% and 98% of patients with ESS of 2, 9 and 16 requiring critical care, respectively. Only 6.2% of patients with ESS ≤7 had an ICUneed, while 97.2% of patients with ESS ≥15 had an ICUneed. The c-statistic of the predictive model was 0.90.

Conclusions: ESS accurately predicts the need for postoperative critical care and ICU admission. In resource-limited settings, ESS may prove useful as an ICU triage tool ensuring a prompt rescue of the clinically deteriorating patient without unnecessary and burdensome ICU admissions.

MeSH terms

Adult
Critical Care*
Databases, Factual
Digestive System Surgical Procedures*
Female
Health Services Needs and Demand*
Hospital Mortality
Hospitalization
Humans
Male
Middle Aged
Postoperative Complications / diagnosis
Postoperative Complications / epidemiology*
Postoperative Complications / therapy
Predictive Value of Tests
Quality Improvement
Risk Assessment
Severity of Illness Index
Triage*