C. M. Dickinson1, N. A. Coppersmith1, H. Huber1, A. Stephen1, D. T. Harrington1 1Brown University School Of Medicine,Surgery,Providence, RI, USA
Introduction: Current recommendations state that patients with peritonitis should be operated on within 1-2 hours. However, there is limited literature that support time-based recommendations or identify where delays exist from the emergency room (ER) to the operating room (OR). We investigated the time course for patients that needed emergency abdominal surgery and evaluated whether time to operation impacted outcomes.
Methods: A retrospective review was done of all non-transferred adult patients over a 5-year period who were admitted from the ER and underwent a non-trauma exploratory laparotomy within 24 hours of admission. To limit the study group to patients with clear emergent indications for surgery, small bowel obstructions without perforations, appendicitis, cholecystitis, GI bleeds, and malignant obstructions were excluded. Demographics, comorbidities, vitals, labs, and operative details were reviewed. Times were noted for presentation(PR) to ER, time of ER physician evaluation(EREval), timing of diagnostic imaging(SCAN), time of signed surgical consult note(SC), and time of case start(OR). Adverse outcomes were identified using ICD-9 codes for infectious complications, wound complications, kidney injury, ileus, cardiovascular complications, and respiratory failure. Chi-square, t-tests, ANOVA and discriminant function analysis were used.
Results: One hundred forty-one patients were reviewed. Mean age was 60.8 years, 55.3% were male, and mean APACHE II was 8.5. Mean time from PR to OR was 597 minutes, PR to EREval 91 minutes, EREval to SCAN 156 minutes, SCAN to SC 147 minutes and SC to OR 205 minutes. Patients that did not develop a complication had a shorter time from EREval to SCAN compared to those who developed complications (113.8 vs 176.8 minutes, p<0.05). Shorter total time to OR (543.7 vs 702.3 minutes, p<0.05) was associated with lower rates of complications. There was no significant difference in time to EREval based on the shift that the patient presented on, however those who had an image obtained during the first shift (7AM-3PM) had longer delays to SCAN (1st shift 204 minutes, 2nd shift 152 minutes, 3rd shift 130 minutes, p<0.05). There were no significant differences based on shift when evaluating time from SCAN to OR. However, those who had a case start time during first shift experienced significantly longer total delays to operation (1st shift 779 min, 2nd shift 527 min, 3rd shift 491 min from arrival to OR, p<0.05).
Conclusion: Increased time to OR was associated with a higher number of complications in patients undergoing emergency abdominal surgery. These delays are spread out over a patient's course, from arriving to the ER, to obtaining imaging and surgical team evaluation. Interestingly it appears that during the first shift patients experience the most delays. Further investigation into the cause for these delays is critical to expediting patient care for those who need emergent abdominal surgery.