Introduction
Annually, >27 million individuals are admitted to US hospitals for emergency general surgery (EGS) with these admissions and costs expected to rise 45% to >$41 billion annually by 2060.1 EGS patients, compared with elective general surgery patients, carry more severe pre-existing illnesses, require more prolonged postoperative mechanical ventilation, require longer intensive care unit (ICU) stays, and have higher rates of mortality.2 Furthermore, approximately half of EGS patients develop postoperative complications, with 22% requiring unplanned readmission within 90 days postsurgery.3–5 Increased risk for poor outcomes remains in this population even after adjusting for preoperative comorbidity and physiological status.5 Together, these findings underline the public health burden of disease in EGS patients as well as the need to better understand and improve factors related to effective management of this population.
One factor likely impacting EGS outcomes is psychological health. Generally, researchers have identified a robust co-occurrence of psychiatric disorders with medical illness and injury.6 7 Concomitant mental illness among medical patients (eg, diabetes) has been shown to impact medical treatment adherence and cost as well as premature mortality risk.8 9 Despite complexities of the EGS population, there is limited empirical work detailing emotional functioning of these patients. That said, provider-based anecdotal evidence of psychological concerns is described in EGS management guidelines; for example, postoperative enterocutaneous fistula guidelines highlight ‘the psychological sequelae, which include depressive illness, anxiety, guilt, and institutionalization’.10 There is also empirical evidence of psychiatric needs in patients with medical stressors often treated through EGS. For example, a qualitative study examining patient experiences with cholecystitis and cholecystectomy found pain associated with cholecystitis ‘can create stress…even more so in those who are vulnerable to psychological stress’ and ‘patients expressed feelings of vulnerability with “no control” over their illness’.11 Currently, assessment of psychological functioning is limited to self-report measures, and these data are often sourced through outpatient, elective encounters and do not speak to the conditions unique to emergency medical interventions. For example, in a meta-analysis examining impact of psychological factors on surgical recovery, most studies did not incorporate the gold standard of psychological evaluation (ie, clinical interview), and most participants underwent only elective procedures.12 These methodological limitations thwart generalizability of conclusions regarding EGS patients.
These gaps in clinical knowledge and practice contrast, for example, with significant advances in the multidisciplinary and holistic care of patients with cancer. Born from specific research efforts identifying the effects of cancer on psychopathology, pain, and fatigue, the American College of Surgeon’s (ACS) Commission on Cancer recognized the psychosocial impact of cancer, leading to a requirement for mental health screening and referral as part of the accreditation process.13 As a result, both research funding and philanthropic efforts have been devoted to identifying effective strategies for improving comprehensive patient care in oncology, leading to improved integrated care to treat patients with cancer.
Altogether, developing a greater, empirical understanding of EGS patients’ psychological presentation within the context of their physical health may help identify patients at risk for adjustment and coping difficulties during hospitalization and recovery. Identifying these at-risk patients early in their hospital course may allow providers to initiate more integrative treatments to mitigate and/or circumvent psychological distress and increase access to psychiatric care; this in turn can potentially reduce physical complaints and recovery complications. To this end, the present study has three aims. First, to identify psychiatric diagnostic rates and symptom severity in a convenience sample of EGS patients; it was hypothesized these rates would be analogous to other hospital-based surgical samples (eg, traumatic injury). Second, to examine how social support and pain experience are related to these psychological sequalae; it was hypothesized social support would be related to less psychiatric distress and that pain would be related to more psychiatric distress. Third, to explore the impact of psychopathology and other characteristics on length of hospitalization as well as on likelihood of 90-day readmission; it was hypothesized more psychiatric distress, more pain, and less social support would increase risk for readmission.