Pa­tients whose emer­gency surg­eries are de­layed have higher risk of dy­ing: study

The Guardian (Charlottetown) - - CLASSIFIEDS/HEALTH - BY SH­ERYL UBELACKER 5)& $"/"%*"/ 13&44

Pa­tients whose emer­gency surg­eries are de­layed due to a lack of op­er­at­ing room re­sources have an in­creased risk of death or a need for ex­tra re­cov­ery time in hospi­tal, a Cana­dian study sug­gests.

Re­searchers at the Ot­tawa Hospi­tal found sur­gi­cal de­lays for pa­tients with se­ri­ous in­juries or life-threat­en­ing con­di­tions such as a hip frac­ture, ap­pen­dici­tis or an aneurysm had al­most a 60 per cent higher risk of dy­ing com­pared to those who re­ceived more timely treat­ment.

The study, pub­lished Mon­day in the Cana­dian Med­i­cal As­so­ci­a­tion Jour­nal, showed that pa­tients who didn’t get into the OR within a stan­dard time frame for their con­di­tion had an al­most five per cent risk of dy­ing, com­pared to a 3.2 per cent risk for those whose surg­eries weren’t de­layed.

On av­er­age, de­layed-surgery pa­tients also stayed in hospi­tal af­ter their op­er­a­tion 1.1 days longer and cost the hospi­tal $1,409 more than pa­tients who did not have to wait.

“For the first time, we have strong ev­i­dence that the sooner you get to the op­er­at­ing room for an emer­gency surgery, the bet­ter off you are, re­gard­less of your con­di­tion be­fore surgery,” said se­nior au­thor Dr. Alan Forster, vi­cepres­i­dent of qual­ity, per­for­mance and pop­u­la­tion health at the Ot­tawa Hospi­tal.

Ur­gent surg­eries are those con­sid­ered nec­es­sary within 24 hours of a pa­tient be­ing di­ag­nosed, in most cases at a hospi­tal emer­gency de­part­ment. Such surg­eries rep­re­sent 13 per cent of all op­er­a­tions per­formed in On­tario, ac­cord­ing to the On­tario Min­istry of Health and Long-Term Care.

“Some surg­eries need to be done very promptly,” said Forster, an in­ternist and re­searcher. “The hip frac­ture is a re­ally good ex­am­ple be­cause that’s one that re­ally should be done within that 24-hour time frame.”

The rea­sons for de­lays were known in 39 per cent of cases. The most com­mon causes for de­lay were that op­er­at­ing rooms were al­ready in use or sur­geons, anes­thetists or sur­gi­cal nurs­ing staff were not avail­able, he said.

“If you only have min­utes or hours to plan, then you re­ally have to have those re­sources avail­able,” said Forster, adding that it’s dif­fi­cult for pa­tients and their fam­i­lies when an ur­gent surgery has to be put off.

“Peo­ple are ob­vi­ously very worried about their loved ones, they’re ob­vi­ously worried about them­selves, they’re of­ten in dis­com­fort as a re­sult ... The best thing is to get folks into the OR im­me­di­ately when they’re sup­posed to be and min­i­mize those anx­i­eties, min­i­mize their pain.”

To con­duct the study, the re­searchers ex­am­ined data from 15,160 adults who had emer­gency surgery at the Ot­tawa Hospi­tal be­tween Jan­uary 2012 and Oc­to­ber 2014. They found that 2,820 of these pa­tients, or al­most 20 per cent, ex­pe­ri­enced a de­lay.

Re­searchers spent the first three months of the study col­lect­ing data on the de­mand for emer­gency surg­eries. In Jan­uary 2013, the hospi­tal be­gan us­ing a new method for sched­ul­ing such op­er­a­tions, in­clud­ing ded­i­cat­ing OR time specif­i­cally for emer­gency pro­ce­dures and spread­ing elec­tive surg­eries more evenly through­out the week.

Af­ter the hospi­tal im­ple­mented this new model, there was a sig­nif­i­cant de­crease in the num­ber of ur­gent surg­eries that had to be de­layed.

“There was a mas­sive im­prove­ment in pa­tients get­ting to emer­gency surg­eries on time with this new model,” said Forster.

“It might seem coun­ter­in­tu­itive, but hav­ing un­used time in ex­pen­sive op­er­at­ing rooms could save both money and lives.”

Still, he said there are cer­tain bar­ri­ers to im­ple­ment­ing a sys­tem with op­er­at­ing suites des­ig­nated for emer­gency surg­eries _ which may at times sit un­used.

“Peo­ple run­ning op­er­a­tions are al­ways look­ing to make sure their bud­gets are main­tained. It’s dif­fi­cult to cre­ate ca­pac­ity and then plan not to use it.”

In a re­lated CMAJ com­men­tary, Dr. David Ur­bach of Women’s Col­lege Hospi­tal, says the study find­ings pro­vide the most cred­i­ble ev­i­dence to date that long de­lays to emer­gency surgery are harm­ful.

“These find­ings will ring true for many of us who have worked in an op­er­at­ing room in a Cana­dian hospi­tal,” writes Ur­bach, sur­geon-in-chief at the Toronto hospi­tal.

“Global hospi­tal bud­gets in an era of con­strained pub­lic fi­nanc­ing force sur­gi­cal de­part­ments to strive for max­i­mum ef­fi­ciency; most op­ti­mize uti­liza­tion of op­er­at­ing rooms and staff at max­i­mum ca­pac­ity for elec­tive surgery, while as­sid­u­ously avoid­ing any un­bud­geted ac­tiv­ity.”

The au­thors note that even though the study was con­ducted at one cen­tre, the find­ings are likely gen­er­al­iz­able to other hos­pi­tals across the coun­try.

“We need to think about how we make OR re­sources avail­able for ur­gent surgery dif­fer­ently,” said Forster.

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Sur­geons work on a hip re­place­ment pro­ce­dure in this un­dated hand­out photo. Pa­tients whose emer­gency surg­eries are de­layed due to a lack of op­er­at­ing room re­sources have an in­creased risk of death or a need for ex­tra re­cov­ery time in hospi­tal, a Cana­dian study sug­gests.

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