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Association between operating room access and mortality for life-threatening general surgery emergencies

Daniel, Vijaya T. MD, MPH; Rushing, Amy P. MD; Ingraham, Angela M. MD; Ricci, Kevin B. MD; Paredes, Anghela Z. MD; Diaz, Adrian MD; Ayturk, M. Didem; Baselice, Holly E. MPH; Strassels, Scott A. Pharma, PhD; Santry, Heena P. MD

Journal of Trauma and Acute Care Surgery: July 2019 - Volume 87 - Issue 1 - p 35–42
doi: 10.1097/TA.0000000000002267

BACKGROUND Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals.

METHODS In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables.

RESULTS Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51–75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1–5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1–2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5–3.1).

CONCLUSION Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence.

LEVEL OF EVIDENCE Therapeutic, level III.

From the Department of Surgery (V.T.D.), University of Massachusetts Medical School, Worcester, Massachusetts; Department of Surgery (A.P.R., K.B.R., A.Z.P., A.D., H.E.B., S.A.S., H.P.S.), Ohio State University Wexner Medical Center, Columbus, Ohio; Center for Surgical Health Assessment (A.P.R., K.B.R., A.Z.P., A.D., H.E.B., S.A.S., H.P.S.), Research, and Policy (SHARP), Ohio State University, Columbus, Ohio; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin, and Department of Quantitative Health Sciences (M.D.A.), University of Massachusetts Medical School, Worcester, Massachusetts.

Address for reprints: Heena P. Santry, MD, Department of Surgery, Ohio State University Wexner Medical Center, 395 W 12th Ave, Columbus, OH 43210; email:

Presentations: This article was presented as an oral presentation at the 32nd Eastern Association for the Surgery of Trauma Annual Scientific Assembly in Austin, Texas from January 15-19, 2019. This article was also the winner of the 2019 Raymond H. Alexander, MD Resident Paper Competition (Clinical Science Paper).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Online date: April 5, 2019

© 2019 Lippincott Williams & Wilkins, Inc.