A. Ingraham1, A. Z. Paredes2, A. Diaz2, A. P. Rushing2, K. B. Ricci2, V. T. Daniel3, D. Ayturk3, H. E. Baselice2, S. A. Strassels2, H. Santry2 3University Of Massachusetts Medical School,Worcester, MA, USA 1University Of Wisconsin,Surgery,Madison, WI, USA 2Ohio State University,Columbus, OH, USA
Introduction: The timing of appendectomy and cholecystectomy, the two most frequent procedures performed non-electively by general surgeons, can be influenced by hospital-level operative resources. We measured the impact of hospital-level structures and processes related to operating room (OR) access on the timing of as well as the outcomes following appendectomy and cholecystectomy.
Methods: In 2015, we surveyed 2,811 US hospitals on emergency general surgery (EGS) practices, including how OR access is assured (e.g., block time, OR staffing, etc.). 1,690 hospitals (60%) responded. We linked survey data to 2015 Statewide Inpatient Database data from 17 states using American Hospital Association identifiers. We identified patients ≥18yrs who underwent an appendectomy or cholecystectomy urgently/emergently for appendicitis or cholecystitis (without choledocholithiasis) respectively. Patients transferred from another acute care facility were excluded. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to measure the association between OR resource variables and the timing of operation (early [date of admission] vs late [any other date]). Similar models measured the association between the timing of operation and major operative complications, systemic complications, and length of stay (LOS).
Results: Of 510 hospitals representing 17 states, 327 (64%) had no block time for EGS cases. Daytime surgeons covering EGS were free from other clinical duties at 59 (12%) hospitals; 234 (46%) hospitals lacked in-house overnight surgeon coverage. A total of 24,195 appendectomy or cholecystectomy patients were identified at these hospitals. 8,536 (97%) patients with appendicitis and 10,299 (67%) patients with cholecystitis underwent early surgery, respectively. Limited block time as well as the absence of dedicated daytime coverage and in-house overnight coverage were associated with decreased odds of an early operation (Table). Overall, late operation was associated with decreased odds of major operative complication (OR 0.75, 95% CI 0.68-0.84), increased odds of systemic complication (OR 1.41, 95% CI 1.29-1.54), and increased LOS (Coef 2.23, 95% CI 2.14-2.32).
Conclusions: While the majority of appendicitis and cholecystitis patients undergo early operation, our findings suggest that efforts to ensure timely access to surgery may reduce time to surgery and possibly result in fewer complications and shorter LOS. Given the large numbers of patients with these diseases seen annually, these results have implications for hospital-level processes to identify and reduce barriers to OR access.
