A QASM June 2023 (Volume 4) Delay to surgery Queensland Audit of Surgical Mortality (QASM) assessors have stated that: 'Delay to surgical intervention plays a significant role in “priming” patients for multiorgan dysfunction … the keys to a good outcome are firstly, minimise delay to surgical intervention and secondly, make the operation as simple and reproducible as possible.'
BACKGROUND
Delay to surgery can have consequences. From emotional complications to financial and health complications, delay to surgery causes more harm than good.1 A temporary delay to surgery may not have an adverse outcome for a patient whose presentation isn’t major or life-threatening, but small problems can quickly progress if not treated in a timely manner. Any prolonged restriction of blood supply can cause mesenteric ischaemia, associated with acute abdominal pain and extremely high risk of further complications. Mesenteric ischaemia causing abdominal pain is associated with a 60% to 80% mortality rate.2 Patients with mesenteric ischaemia can present in various ways. The critical factors influencing outcomes for these patients are timely diagnosis and intervention.2, 3 QASM reviewed in-hospital death data between 1 January 2018 and 31 December 2022. Delay to surgery was noted in 5.7% (283/4,984) of inhospital deaths (Table 1). Delay is defined as the time from presentation to surgical diagnosis.4 Most patients who experienced a delay to surgery were admitted under General Surgery (47.7%), Orthopaedic Surgery (18.4%), Cardiothoracic Surgery (9.9%), Vascular Surgery (8.8%), Neurosurgery (7.8%) or Urology (5.3%). Of the patients with delay to surgery, 88% were admitted to public hospitals and 12% to private hospitals. Most patients with delays (92.6%) were 50 years or older. Most of the delays were associated with surgical units, medical units, misinterpretation of results, incorrect test and/ or inexperience of staff. Delays for some patients were associated with issues with a GP referral (5.3%; 15/283), results not being reviewed (14.1%; 40/283), or unavoidable factors (34.6%; 98/283). Unavoidable factors included: inter-hospital transfers, inconclusive radiology, and non-specific diagnosis resulting in medical admissions.Orthopaedic Surgery and Neurosurgery patients were significantly less likely to experience a delay to surgery compared with those in General Surgery, after adjusting for age, sex and American Society of Anesthesiologists classification.
Table 1. Patients with delay to surgery by surgical specialty and delay associations (n = 283/4,984; 5.7%) Surgical specialty
Case affected by delay
Total cases n = 4,793**
N = 277 (5.8) n (%)
Adjusted odds ratio 95% CI
Surgical n = 78 (28.2%)
Medical n = 109 (38.5%)
Misinterpretation of results n = 59 (21.3%)
Incorrect test n = 47 (17.0%)
Inexperience of staff n = 52 (18.8%)
General Surgery (n=1,792)
135 (7.4)
Reference
55 (3.1)
47 (2.6)
36 (2.0)
23 (1.3)
30 (1.7)
Orthopaedic (n=1,252)
52 (4.2)
0.55 (0.39–0.77)*
9 (0.7)
30 (2.4)
7 (0.6)
6 (0.5)
5 (0.4)
Cardiothoracic (n=423)
28 (6.6)
0.76 (0.49–1.18)
2 (0.5)
13 (3.1)
4 (0.9)
6 (1.4)
6 (1.4)
Vascular (n=401)
25 (6.2)
0.94 (0.52–1.70)
7 (1.7)
4 (1.0)
5 (1.2)
4 (1.0)
7 (1.7)
Neurosurgery (n=709)
22 (3.1)
0.26 (0.15–0.46)*
5 (0.7)
7 (1.0)
3 (0.4)
5 (0.7)
3 (0.4)
Urology (n=216)
15 (6.9)
0.94 (0.52–1.70)
0 (0.0)
8 (3.7)
4 (1.9)
3 (1.4)
1 (0.5)
Unit associated with delay
Cause of delay
Notes: * Statistically significant ** Excludes any surgical specialties with 5 or fewer patients and those who had delays because numbers too low and patients would be identifiable (i.e. oral/ maxillofacial surgery, obstetrics and gynaecology, paediatric surgery, and plastic and reconstructive surgery; n = 6/191). Adjusted odds ratio adjusted for age, sex, and American Society of Anesthesiologists (ASA) classification. CI = confidence interval Each delay may be attributed to multiple associations and causes, therefore the associations and causes will not total 100%.
QASM data show that delay to surgery has decreased over time. In 2012, QASM reported that delay was experienced for 9.3% of patients (293/3,139) across all surgical specialties (deaths reviewed between June 2007 and December 2011).4 This compares to the findings from the analysis above (January 2018 through December 2022; Table 1). The data show a 3.6% decrease in delay to surgery over the subsequent years while incorporating an additional 1,845 patients reviewed by QASM (5.7%; 283/4,984). This is a significant decrease in the reporting of delay to surgery (Odds Ratio 0.60; 95% CI 0.51 – 0.71). Decreases in delays to surgery may be attributed to many factors, including QASM initiatives such as targeted seminars, publications and educational activities that highlight the main causes of delays. QASM has provided recommendations to minimise the occurrence of preventable delays. It is encouraging that delays to surgery are decreasing because the consequences can be life-threatening. The case study below highlights the consequences of delay to surgery.