Patient Safety Tip of the Week
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
It’s well known that delays in performing surgery for hip
fracture increase patient morbidity and mortality. But the relationship has
been less well defined for other types of emergency surgery. Now Canadian
researchers have published a new study that sheds light on the impact of delays
for all types of emergency non-cardiac surgery (McIsaac 2017). McIsaac and colleagues at Ottawa Hospital analyzed cases
where surgery for emergency cases was delayed compared to those performed
without delay. They found that 18.6% of
over 15,000 emergency cases between January 2012 and October 2014 experienced a
delay. They found that in-hospital mortality in delayed cases was 4.9% compared
to 3.2% in those without delay. They then did matching based on propensity
scores in attempt to account for confounding variables other than delays. That adjusted
analysis revealed that delays were significantly associated with mortality (OR
1.56), increased length of stay (incident rate ratio 1.07), and higher total
costs (incident rate ratio 1.06). The number needed to harm for mortality was
60.
Moreover, they found
that system issues dominated the reasons for delay (accounting for over 86% of
cases with documented reasons for delay). They found that availability of
personnel was a common reason for delays. That unavailability was most often
for the surgeon but occasionally also involved anesthesiologists or nurses.
Availability of physical resources (operating room, post-anesthesia recovery
unit, equipment) was also a common reason for delays. And many cases had
multiple reasons for delay. Many cases were bumped by higher priority cases. Patient-specific
reasons for delay were less common but usually involved medically complex or
decompensated patients who needed stabilization prior to surgery.
You need to read the
McIsaac article to understand the way they defined
delays and how they classified degree of urgency. But suffice it to say that they
determined an expected wait time for surgery for each type of surgery and its
classified degree of urgency. They then found another very interesting trend.
As wait time increased up to 1.1 multiples of the accepted wait-time window the
odds of mortality increased. But for wait times beyond 1.1 multiples, the odds
of mortality actually decreased. They thus postulated there may be two distinct
subgroups of patients: those that truly need emergent surgery and those that
have a survivorship bias.
A key point of the McIsaac article and the accompanying editorial (Urbach 2017)
is that in allocating human and financial resources for the OR, we need to take
a strong look at downstream costs. While fixing some of the system issues
leading to surgery delays may be expensive, there may well be cost offsets in
the long run (due to reduced length of stay and other costs).
At first blush, these findings might seem to contradict a
point we made in our several columns on “after-hours” surgery (see the list
below). In those columns we’ve discussed the multiple factors that may lead to
less desirable outcomes when surgery is performed after-hours and in some of
those columns we’ve intimated that many cases may be more safely performed the
following morning rather than at night.
But the McIsaac study was not a
study of time of day surgery was done. Rather, it looked at delays any time of
day. And many of the system factors identified by McIsaac
and colleagues leading to delays are also the same ones we’ve identified in
after-hours cases.
So the conclusions by McIsaac et
al. are not really contradictory to those in our prior columns. We are in
agreement that there are multiple system issues that interfere with optimal
care when emergent cases are either delayed or done after-hours. Attention to
correcting those factors may lead to better outcomes.
In our October 4, 2016
Patient Safety Tip of the Week “More
on After-Hours Surgery” we
discussed why “after hours” surgery might 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. For surgery, in particular, the impact of time of day on
teamwork is important. You are often 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 or
experience as your regular daytime team (because many hospitals have
“seniority” policies, you may have less experienced personnel on your OR
“on-call” teams) 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, sterile processing,
etc.) 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.
The Urbach editorial (Urbach 2017)
suggests that use of team-based surgical care models may be one way to address
some of the system-level barriers to timely emergency surgery. Working in such
teams may allow cross-coverage so that delays due to a single surgeon being
occupied elsewhere are minimized. Obviously such models are best implemented at
academic medical centers or larger urban hospitals and are more difficult to
implement at rural or smaller community hospitals.
We highly recommend hospitals take a hard look at surgical
cases done “after hours” and all your cases of “emergency” surgery. You need to
look at the morbidity and mortality statistics of such cases. You need to
identify factors contributing to delays in such cases and 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.
The study by McIsaac et al. suggests
that investment in personnel and system issues that may lead to delays in
surgery are likely to be offset by downstream savings (in reduced length of
stay and other costs).
Some of our previous
columns on the “after-hours” surgery:
·
September 2009 “After-Hours
Surgery – Is There a Downside?”
·
October
2014 “What
Time of Day Do You Want Your Surgery?”
·
January
2015 “Emergency
Surgery Also Very Costly”
·
September
2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
·
October 4,
2016 “More
on After-Hours Surgery”
References:
McIsaac DI, Abdulla K, Yang H, et
al. Association of delay of urgent or emergency surgery with mortality and use
of health care resources: a propensity score–matched observational cohort
study. CMAJ 2017; 189: E905-E912 published online July 10, 2017
http://www.cmaj.ca/content/189/27/E905.full
Urbach DR. Delivering timely
surgery in Canadian hospitals. CMAJ 2017; 189: E903-E904
http://www.cmaj.ca/content/189/27/E903.full
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