Exploring Diagnostic Challenges and Performance Feedback in Older Adult Emergency General Surgery.

Abstract

A growing number of emergency general surgery (EGS) admissions comprise of adults age 65 years and older, who are more likely to experience missed or delayed diagnoses, and subsequently worse postoperative outcomes. We aimed to ascertain the perspectives of clinicians on the diagnostic challenges unique to older adults with EGS conditions and strategies to improve feedback. In this qualitative study, semi-structured focus groups were conducted with frontline clinicians with experience in providing high volume care to older adult EGS patients to explore diagnostic challenges, tools, and feedback strategies. Questions focused on clinical gaps and approaches, tools, and the mechanisms in place to provide feedback on patient diagnosis and assessment. Focus groups were transcribed and qualitatively analyzed using an inductive approach. Twenty-two clinicians participated in one of six focus groups. Clinicians reported three key diagnostic challenges: nontextbook presentations, comorbidities, and older-age specific complications. Nondiagnostic factors remained high priorities including functional health status, patient preferences, family involvement, and health related social needs. Practical tools addressing these gaps included the use of multidisciplinary expertise, surgical risk calculators, cognitive assessments, functional health assessments, and protocols guiding goals of care discussions. Participants shared barriers and facilitators for implementation of these tools. Frontline clinicians identified several high priority considerations unique in EGS for older adults. To address these, context-specific tools and strategies were detailed and inform ongoing work to incorporate feedback and solutions into frontline settings. Future work in quality improvement should incorporate these high priority areas into existing quality improvement frameworks.