Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort Study
ABSTRACT Surgical care is delivered around the clock. Elective cases within the Veterans Affairs health system starting after 4 pm appear to have an elevated risk of morbidity, but not mortality, compared with earlier cases. The relationship between operation start time and patient outcomes is not described in private-sector patients or for emergency cases.
We performed a retrospective cohort study of 56,920 general and vascular surgical procedures performed from October 2001 through September 2004, and entered into the National Surgical Quality Improvement Program database. Operation start time was the independent variable of interest. Random effects, hierarchical logistic regression models adjusted for patient, operative, and facility characteristics. Two independent models determined associations between start time and morbidity or mortality. Subset analysis was performed for emergency and nonemergency cases.
After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am (odds ratio = 1.752; p = 0.028; reference 7:30 am to 9:30 am). As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity (odds ratio = 1.32; p < 0.0001). Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period (odds ratio = 1.48; p = 0.001).
Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.
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ABSTRACT: Background Laparoscopic cholecystectomies may be performed at night in high-volume acute care hospitals. We hypothesized that non-elective nighttime laparoscopic cholecystectomies are associated with increased post-operative complications. Study Design We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected regarding demographics, operative time, time of incision, length of stay, 30-day postoperative complications (bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, bleeding) and death. Statistical analyses were performed using STATA 12. Results Over 8 months, 356 patients had non-elective laparoscopic cholecystectomies. A majority were female (289, 81.1%) and Hispanic (299, 84%). There were 108 (30%) nighttime surgeries. There were 29 complications in 18 patients – there were fewer daytime than nighttime patients who had at least one complication (4.0 vs. 7.4%, p=0.18). On multivariate analysis, age (OR 1.06 per year, 95% CI 1.02 to 1.10, p=0.002), case duration (OR 1.02 per minute, 95% CI 1.01 – 1.02, p=0.001), and nighttime surgery (OR 3.33, 95% CI 1.14 – 9.74, p=0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs. 2 days, p<0.001). Conclusions Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.Journal of the American College of Surgeons 10/2014; 219(4). DOI:10.1016/j.jamcollsurg.2014.05.009 · 4.45 Impact Factor
The spine journal: official journal of the North American Spine Society 04/2014; 14(4):725-6. DOI:10.1016/j.spinee.2013.05.043 · 2.80 Impact Factor
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ABSTRACT: Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention. A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined. During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically. Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication.02/2015; 9(1-2). DOI:10.5489/cuaj.2341