Patient Safety Tip of the Week
October 24, 2017 Neurosurgery and
Time of Day
We’ve done several columns highlighting the phenomenon that
surgery done “after hours” may be
associated with more complications than surgery done during normal daytime
working hours (see the list of columns at the end of today’s column).
In our What's New in the Patient Safety World columns for
September 2009 “After-Hours
Surgery – Is There a Downside?” and October
2014 “What
Time of Day Do You Want Your Surgery?” we discussed studies that showed for
certain types of orthopedic surgery after hours there was an increased need for
reoperations for removal of painful fracture hardware (Ricci
2009) and laparoscopic cholecystectomies done at night compared to
daytime were associated with a higher conversion rate to open cholecystectomy
(11% vs 6%) (Wu
2014). We also noted previous
studies by Kelz and colleagues that showed increased
morbidity in non-emergent surgical cases done “after hours”, one in the VA
system (Kelz 2008)
and another in a private hospital
setting (Kelz
2009). And our January 2015 What's New in the Patient Safety World column “Emergency
Surgery Also Very Costly” suggested, in addition to the human costs of
after-hours surgery there may also be financial costs.
In our October 4, 2016
“More
on After-Hours Surgery”,
we noted Canadian researchers (WFSA 2016)
showed that surgical mortality does vary by time of day and that, after adjustment for age and ASA scores,
patients operated at night (11:30 PM-7:29 AM) were 2.17 times more likely to
die within 30 days than those operating on during regular daytime working hours
(7:30 AM-3:29 PM). Those operated on in the late day (3:30 PM-11:29 PM) were
1.43 times more likely to die than those operated on during regular daytime
working hours.
Now add to those previous studies a new one which looked at
neurosurgical procedures at the University of Michigan Health System (Linzey
2017). Noting that reported outcomes are worse at night for things
like coronary angioplasty, orthopedic surgery, and colorectal surgery, Linzey and colleagues reviewed their own experience in
neurosurgery. There was a higher percentage of more minor procedures late in
the day. As you’d expect, complications were more frequent in those cases done
as “emergent” and in those patients with more comorbidities (likelihood of
complications increasing 10% for each comorbidity). But after adjusting for all
patient and procedure characteristics, the odds
of a complication were increased by more than 50% for start times between 21:01
and 07:00 (OR 1.53). The odds ratio was even higher when severe
complications were considered (OR 1.61).
Linzey and colleagues have some
thoughtful comments on why a “night effect” might not have been seen in some
reported series of transplant surgery. They noted that transplant surgery is
done by teams who are used to working together and who frequently perform
surgery at night. Transplant teams are also less reliant on housestaff.
And transplant teams are typically doing one type of surgery, compared to other
specialties which may be performing multiple different types of surgery at
night.
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. Obviously, fatigue (for all members of the surgical team) may
be a factor. But 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.
All of this, of course, needs to be balanced against the
need to do truly emergent cases as soon as possible. In our August 15, 2017 Patient Safety Tip of the
Week “Delayed
Emergency Surgery and Mortality Risk” we noted a study (McIsaac 2017) showing
that delays in performing emergent cases were associated with increased mortality
(OR 1.56), increased length of stay (incident rate ratio 1.07), and higher
total costs.
We highly recommend hospitals take a hard look at surgical
cases done “after hours”. You need to look at the morbidity and mortality
statistics of such cases. In particular, you need to determine which cases
truly needed to be done after hours (emergency cases) 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.
Some of our previous
columns on “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”
·
August
15, 2017 “Delayed
Emergency Surgery and Mortality Risk”
References:
Ricci WM, Gallagher B, Brandt A, Schwappach
J, Tucker M, Leighton R. Is After-Hours Orthopaedic
Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J
Bone Joint Surg Am. 2009; 91: 2067-2072
Wu JX, Nguyen AT, de Virgilio C, et al. Can it wait until
morning? A comparison of nighttime versus daytime cholecystectomy for acute
cholecystitis. Amer J Surg
2014; published online first September 20, 2014
http://www.americanjournalofsurgery.com/article/S0002-9610%2814%2900438-3/abstract
Kelz, R.R., Freeman, K.M.,
Hosokawa, P.W. et al. Time of day is associated with postoperative morbidity:
an analysis of the national surgical quality improvement program data. Annals
of Surgery 2008; 247: 544–552
http://www.ncbi.nlm.nih.gov/pubmed/18376202?dopt=Abstract
Kelz RR, Tran TT, Hosokawa P, et
al. Time-of-day effects on surgical outcomes in the private sector: a
retrospective cohort study. J Am Coll Surg 2009; 209(4): 434-445.e2.
http://www.journalacs.org/article/S1072-7515%2809%2900507-9/abstract
WFSA (World Federation of Societies of Anaesthesiologists).
Five-year study reveals patients operated on at night twice as likely to die as
patients who have daytime operations. Science Daily 2016; August 29, 2016
Regarding:
Wang N, et al. Retrospective analysis of time of day of
surgery and its 30 day in-hospital postoperative mortality rate at a single
Canadian institution. Poster presentation 601. World Congress of Anaesthesiologists 2016
https://www.sciencedaily.com/releases/2016/08/160829192642.htm
Linzey JR, Burke JF, Sabbagh A, et al. The Effect of Surgical Start Time on
Complications Associated With Neurological Surgeries. Neurosurgery 2017;
Published online 13 October 2017
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
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