Increased risk environment for emergency general surgery in the context of regionalization and specialization

The pressures on tertiary hospitals with increased volume and complexity related to regionalization and specialization has impacted upon availability of operating theatres with consequent displacement of emergencies to high risk out of hours settings.

A retrospective review of an electronic emergency theatre list prospectively maintained database was performed over a two year period. Data gathered included type of operation performed, Time to Theatre (TTT), operation start time and length of stay (LOS).

Of 7041 emergency operations 25% were performed out of hours. 2949 patient had general surgical emergency procedures with 910 (30%) performed out of hours. 53% of all emergency laparotomies and 54% of appendicectomies were out of hours. 57% of cases operated on out of hours had been awaiting surgery during the day. Mean TTT was shorter for those admitted at the weekend compared to those admitted during the week (15.6 vs 24.9 h) (p < 0.0001).

The majority of major emergency surgery is performed out of hours in a way unfavorable to good clinical outcomes. It is of concern that more than half of the most life threating procedures involving laparotomy, take place out of hours. Regionalization needs to be accompanied by infrastructure planning to accommodate emergency surgery.