EP757 - Who should manage acute colorectal surgical conditions?: Recommendations from a modified Delphi panel

Purpose/Background: Both acute care (ACS) and colorectal (CRS) surgeons commonly manage patients presenting to the emergency department (ED) with acute lower gastrointestinal surgical conditions. No consensus guidelines exist regarding which service is best suited to manage specific conditions, considering patient-, practice-, and surgeon-specific factors. Using a modified Delphi methodology, we sought to create a guideline for management of common conditions in teaching hospitals where both ACS and CRS practice.

Methods/Interventions: A diverse, representative panel of expert surgeons (7 ACS, 7 CRS) participated in two online Delphi surveys and two qualitative discussion-based Delphi rounds via video-conference. Consensus threshold was defined a-priori at 70%. In the first round, surgeons voted on who should manage 20 different lower GI surgical conditions (ACS, CRS, or either) and conditions without consensus were discussed. In the second round, surgeons ranked the importance of 12 patient, surgeon, and logistical factors in deciding which specialty should manage a condition. Factors that did not reach consensus as being of minor or major importance were discussed further.

Results/Outcomes: Our expert panel reached consensus on who should manage 10 of 20 conditions (50%) on the round 1 survey. During cross-specialty discussion, the panel identified nuanced aspects of patient presentation that determined the most appropriate service for the remaining 10 conditions (Table 1). Key themes that arose during qualitative discussion included the importance of CRS for complex pelvic dissection and disease processes involving the rectum. In the second round, consensus was achieved regarding 5 factors that impacted surgeon decision-making, including patient acuity, surgeon expertise, and surgeon availability (major importance), and resident choice and prior surgery with ACS elsewhere (minor importance). Key themes that arose during discussion of the 7 decision-making factors without consensus included the importance of collaboration, the relative flexibility of the ACS schedule, the expertise of ACS in managing surgical emergencies, and the necessity of CRS operating overnight and on weekends when their expertise would substantially improve patient care.

Conclusion/Discussion: This collaborative interdisciplinary ACS and CRS modified Delphi expert panel achieved consensus on which specialty should manage 10 of 20 surgical conditions, with service allocation for the remaining conditions based on specific aspects of patient presentation. If used prospectively in teaching hospitals with both ACS and CRS, these guidelines may potentially help guide resource allocation, streamline patient care, minimize inter-specialty friction, and improve patient outcomes.

Table 1
Table 1. The 20 common acute lower gastrointestinal conditions examined by our Delphi panel. Conditions with "nuanced consensus" after the first round were examined at qualitative discussion-based Delphi rounds.