title: The nature, patterns, clinical outcomes, and financial impact of intraoperative adverse events in emergency surgery.
abstract: BACKGROUND
  Little is known about intraoperative adverse events (iAEs) in emergency surgery (ES). We sought to describe iAEs in ES and to investigate their clinical and financial impact.
  
  
  METHODS
  The 2007 to 2012 administrative and American College of Surgeons-National Surgical Quality Improvement Program databases at our tertiary academic center were: (1) linked, (2) queried for all ES procedures, and then (3) screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture/laceration". Flagged cases were systematically reviewed to: (1) confirm or exclude the occurrence of iAEs (defined as inadvertent injuries during the operation) and (2) extract additional variables such as procedure type, approach, complexity (measured by relative value units), need for adhesiolysis, and extent of repair. Univariate and multivariate analyses were performed to assess the independent impact of iAEs on 30-day morbidity, mortality, and hospital charges.
  
  
  RESULTS
  Of a total of 9,288 patients, 1,284 (13.8%) patients underwent ES, of which 23 had iAEs (1.8%); 18 of 23 (78.3%) of the iAEs involved the small bowel or spleen, 10 of 23 (43.5%) required suture repair, and 8 of 23 (34.8%) required tissue or organ resection. Compared with those without iAEs, patients with iAEs were older (median age 62 vs 50; P = .04); their procedures were more complex (total relative value unit 46.7, interquartile range [27.5 to 52.6] vs 14.5 [.5 to 30.2]; P < .001), longer in duration (>3 hours: 52% vs 8%; P < .001), and more often required adhesiolysis (39.1% vs 13.5% P = .001). Patients with iAEs had increased total charges ($31,080 vs $11,330, P < .001), direct charges ($20,030 vs $7,387, P < .001), and indirect charges ($11,460 vs $4,088, P < .001). On multivariable analyses, iAEs were independently associated with increased 30-day morbidity (odds ratio, 3.56 [CI, 1.10 to 11.54]; P = .03) and prolonged postoperative length of stay (LOS; LOS >7 days; odds ratio, 5.60 [1.54 to 20.35]; P = .01]. A trend toward increased mortality did not reach statistical significance.
  
  
  CONCLUSIONS
  In ES, iAEs are independently associated with significantly higher postoperative morbidity and prolonged LOS.
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Elie P
authors.initials: EP
authors.lastname: Ramly
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Jordan D
authors.initials: JD
authors.lastname: Bohnen
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Maha R
authors.initials: MR
authors.lastname: Farhat
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Shadi
authors.initials: S
authors.lastname: Razmdjou
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Michael N
authors.initials: MN
authors.lastname: Mavros
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Yeh
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Jarone
authors.initials: J
authors.lastname: Lee
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Butler
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: De Moya
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA. Electronic address: hkaafarani@mgh.harvard.edu.
authors.forename: Haytham M A
authors.initials: HM
authors.lastname: Kaafarani
mesh_terms: D000328:Adult; D000368:Aged; D016208:Databases, Factual; D004638:Emergency Treatment; D005260:Female; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D007431:Intraoperative Complications / Q000191:economics / Q000401:mortality*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000191:economics / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000191:economics / Q000379:methods / Q000401:mortality*; D014481:United States
keywords: Emergency surgery; Intraoperative adverse events; Patient safety