The cost of delay: Evaluating the effectiveness of tiered operating room postings on patient outcomes

Most centers use a tiered operating room (OR) posting system. This system is based on patient physiology and the potential for deterioration of their condition because of the pathology that requires operative intervention. If those criteria are respected, then meeting those time goals should result in better patient outcomes. We sought to determine the effect of patients meeting the time goals within the tiered posting systems on patient outcomes.

A retrospective review at a single academic center was performed on all patients posted for the OR by the acute care surgery (ACS) service over a 9-year period. The posting system was E1, E2, E4, E12, and Add On/Elective, which designated emergent and the number of hours they were to go to the OR after posting. Only emergent cases with one operation were included for analysis, and cases were further stratified by day and night.

There were 7,520 patients with 4,544 meeting final inclusion criteria with 2,042 daytime cases and 2,502 nighttime cases. The 30-day mortality was significantly higher in the daytime patients who did not meet the posting goal (4.4% vs. 2.5%, p  = 0.024). In a regression analysis controlling for age, Charlson Comorbidity Index, and shock index, failure to reach the OR in a timely fashion remained an independent predictor of death (adjusted odds ratio, 2.1 [95% confidence interval, 1.2-3.8]; p  = 0.014). There was no difference in nighttime cases.

Acute care surgery care is predicated on timely intervention. Tiered OR posting systems are intended to get patients to the OR to achieve early source control and prevent further deterioration. There is a price to pay when those goals are not reached with an increased risk of death. ( J Trauma Acute Care Surg . 2026;100: 897- 900. © 2026 American Association for the Surgery of Trauma.).

Therapeutic and Care Management; Level IV.