Surgery done on an emergency basis and surgery done “after-hours” is associated with more complications, more morbidity, and often more mortality (see our What’s New in the Patient Safety World columns for September 2009 “After-Hours Surgery – Is There a Downside?”, October 2014 “What Time of Day Do You Want Your Surgery?”, and December 2014 “Another Procedure to Avoid Late in the Day or on Weekends”).
One consideration we’ve not discussed much is cost. Cases done after hours have variable costs higher than those done during normal hours (overtime, etc.) and the resultant increase in complications and morbidity have additional incremental costs as well. Since most cases are reimbursed with DRG or similar methodology hospitals seldom recoup the full incremental costs of doing such cases after hours.
Now a new study has assessed the financial impact of emergency vs. elective surgery (Haider 2014). Using Nationwide Inpatient Sample (NIS) data the authors investigated costs and mortality for three procedures: abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm. The adjusted mean cost differences for emergent versus elective care ranged from $5309.78 to $8741.22 for the three procedures. The authors estimate that if 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion. Elective surgery patients had significantly lower adjusted odds of mortality for all procedures.
Of course, there are big differences between the types of cases described by Haider et al. and those we have previously described. Most of the ones we’ve discussed are not likely true emergencies (even though they are often categorized as such). Those described by Haider et al. probably were truly emergent (eg. rupture of an AAA, bowel obstruction from a colon cancer, etc.). Moreover, the three conditions chosen for analysis by Haider et al. are ones where access to primary care and screening may have led to earlier detection and interventions that need not be done on an emergent basis. The message in the Haider study, therefore, is important for health plans and accountable care organizations as well as hospitals.
Nevertheless, you get the picture: surgeries that can be done on an elective rather than emergency basis are less costly – from both a human and financial perspective. We again urge all hospitals to take a look at surgeries and procedures done “after hours” and determine how often such cases are truly “emergent”. When you identify those that were not truly “emergent” you need to do root cause analyses and identify what factors contributed to the decision to intervene after hours and which could be potentially modifiable by system changes.
Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.
We highly recommend hospitals take a hard look at surgical cases done “after hours”. In particular, you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
Haider AH, Obirieze A, Velopulos CG, et al. Incremental Cost of Emergency Versus Elective Surgery. Annals of Surgery 2014; published online ahead of print December 17, 2014
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