Extending Enhanced Recovery to Operating Room: Outcomes for Operative Procedures Finishing After 7pm

Deborah S Keller, MS, MD, James W Fleshman, Jr., MD, FACS, FASCRS, Walter Peters, MD, MBA, FACS, FASCRS. Baylor University Medical Center

Background: While working to optimize outcomes, the impact of case timing and operative efficiency warrants investigation. Our goal was to determine if there is increased morbidity and mortality for elective colorectal procedures ending after 7pm. Our hypothesis was that elective cases that end after 7pm are associated with longer operative times, longer lengths of stay(LOS), and higher postoperative complications and readmission rates that comparable earlier cases.

Methods: ACS NSQIP was queried for elective inpatient colorectal resections from 1/1/15-12/31/15. Procedures were stratified into those completed before 7pm(standard) and after 7pm(late). Univariate analysis was performed to identify differences in perioperative and outcome variables between the standard and late groups. Groups were evaluated on demographic variables to validate comparability. The main outcome measures were the expected versus actual complication rates, operative time, LOS, and readmission rate across groups.

Results: During the study period, 363 elective cases were studied: 294(81%) standard and 69(19%) late. The standard and late groups were similar in age, comorbidity, and surgeon experience. The mean BMI was significantly higher in the standard versus the late group(28.53 (SD5.78) vs. 26.17 (SD6.62); p=0.03). The primary diagnosis was diverticulitis in the late group(31.88%) and colon caner is the standard group(32.65%). The main procedure performed was an open low anterior resection in both groups (26.09% late, 21.77% standard). The operative time was significantly shorter in the standard versus late group(179.38 (SD100.66) min vs. 259.01 (SD106.89) min, p<0.01). The expected complication rate was 16.9% in the standard group, and 18.0% in the late group. The actual complication rate was 14.6% in the standard group, and 23.2% in the late group. Specifically, complications were higher for wound infections, urinary tract infections, deep vein thrombosis, C. Difficile infection, and sepsis. The mean LOS was significantly shorter in the standard group(5.89 (3.12) vs. 7.77 (6.59), p=0.04). Post discharge, the readmission rate was significantly lower in the standard compared to the late group(8.50% vs. 13.04%, p=0.03).

Conclusions: Elective colorectal procedures completed after 7pm have higher than expected complication rates. Late cases were associated with longer operative times and higher readmission rates compared to a similar cohort finishing before 7pm. As late case completion time appears to have a negative, preventable impact on patient safety and quality, efforts for more efficient workflow and scheduling are warranted. This administrative view demonstrates attention is needed at the institutional level to drill down on root causes on this matter.