European Journal of Cardiovascular Medicine

Emergency surgical care is inherently time-sensitive; delays from Emergency Department arrival to surgical intervention are linked to increased morbidity and mortality. A study of 1,199 emergency general surgery (EGS) patients found that operations delayed for 6.7–10.7 hours after initial evaluation doubled mortality risk, with delays beyond 24 hours posing even greater risk.  Literature indicates that each hour of delay—especially beyond 16 hours in conditions like gastrointestinal perforation—is associated with higher rates of ICU readmission and complications.   Delays arise from factors at both system and patient levels, including operating room (OR) unavailability, staffing shortages, delayed consent, and required preoperative investigations.  In low- and middle-income countries, logistical and infrastructural constraints in emergency surgery are particularly pronounced.   However, there is a paucity of prospective data from Indian tertiary care centers that quantify each stage of delay. This study aims to evaluate total waiting time and identify contributing factors across defined intervals, to guide targeted interventions and improve emergency surgical outcomes.

Aim and Objectives: This study aims to assess the total waiting time for emergency surgeries and identify contributing factors by analyzing delays across defined intervals, categorized into patient, disease, and hospital-related causes.

A prospective observational study was conducted over a period of 60 days, from 1st March 2025 to 30th April 2025, in the Emergency Department of a tertiary care hospital. A total of 100 patients who presented with surgical emergencies and required operative intervention were enrolled in the study.

Inclusion criteria included all patients diagnosed with a surgical emergency and admitted through the Emergency Department during the study period. Exclusion criteria included:

·         Emergency surgeries not routed through the Emergency Department.

·         Canceled or postponed surgeries after shifting to the Operation Theatre (OT).

·         Surgeries performed by departments other than General Surgery and Orthopedics, to avoid interdepartmental variation and bias.

Data were recorded using a structured data collection form designed after reviewing past emergency surgery records. When required, in-depth interviews were conducted with patients/relatives and healthcare providers for clarification and qualitative insights.

Definition of Waiting Time: The waiting time was defined as the duration from the time of patient arrival at the Emergency Department to the time of the first surgical incision. For detailed analysis, the waiting period was divided into five intervals:

1.       Arrival at ED → First surgical consultation

2.       Surgical consultation → Decision to operate

3.       Decision to operate → Shift to OT

4.       Arrival in OT → Anesthetic consultation

5.       Anesthetic consultation → Surgical incision

Factors Analyzed and Data Analysis: Contributing factors to surgical delays were grouped into three domains: patient-related (age, gender, consent delay, logistics), disease-related (diagnosis, comorbidities, investigations, pre-op interventions), and hospital-related (OT availability, staff, interdepartmental consultations, emergency workload). Data were entered into SPSS version 26, validated, and analyzed to assess associations between delay intervals and contributing factors.

A prospective observational study was carried out over a 60-day period in the Emergency Department of a tertiary care hospital, enrolling 100 patients who required emergency surgical intervention. Each patient was assessed from the point of arrival in the emergency department to the initiation of surgical incision. The total waiting time was segmented into five defined intervals. Factors contributing to delays were systematically classified into three categories: patient-related (such as delayed consent and financial limitations), disease-related (including diagnosis and preoperative investigations), and hospital-related (such as operation theatre availability, staffing, and interdepartmental consultations).

Table 1: Demographic Profile of Patients

Table 2: Department Distribution

Table 3: Interdepartmental Consultations

Table 4: Types of Preoperative Anesthesia

Mean Waiting Time for Each Interval

Delays and Contributing Factors

Our study confirms that delays in emergency surgical procedures are multifactorial, influenced by patient, disease, and system-level factors. The prolonged waiting time—mean total time of 737 minutes (≈12.3 hours)—is largely attributable to hospital-level issues, particularly operation theater (OT) unavailability (61%), mirroring earlier findings where pre-occupied OTs accounted for nearly 60% of delays.

Delays in emergency surgical intervention are unequivocally linked to poorer patient outcomes, encompassing higher morbidity, prolonged hospital stays, and increased mortality. A retrospective study of patients demonstrated that operations delayed beyond 48 hours after hospital admission were associated with significantly higher 30-day mortality and major complications, compared with earlier surgeries.  In their study Smith et al. found that urgent or emergency surgeries performed during nights or weekends carried a 27% higher risk of short-term mortality than those done on weekdays.   Furthermore, even shorter delays before emergency abdominal surgery in low- and middle-income countries have been associated with significantly elevated perioperative mortality.  Together, these findings underscore that each hour of delay in emergency surgery may carry measurable risks, reinforcing the critical need for system-level interventions that expedite operative care to improve outcomes.

System and organizational factors are the predominant contributors to delays in emergency surgery. In our study, 61% of delays were related to operation theatre unavailability, a trend echoed in Wyatt et al.'s UK district hospital study, where 47% of emergency cases faced theatre delays—often due to elective list overruns with after-midnight workloads dropping from 26% to 10% when afternoon OT and anesthetic availability were ensured.  Further compounding this, the "weekend effect" has been identified as a consistent detriment: a meta-analysis showed a 27% higher odds of short-term mortality for weekend emergency surgeries compared to weekdays.6 Such findings underscore that inadequate staffing, restricted OT access, and insufficient coordination during off-hours significantly prolong waiting times and harm outcomes. Our results affirm the need for structural reforms like dedicated emergency theatres, bolstered after-hours teams, and improved scheduling to reduce systemic delays in emergency surgical care.

While hospital constraints are dominant, patient-related delays (e.g. consent delays [6%], arranging finances [14%], blood logistics [11%]) and disease-related requirements (e.g., consultations [26%], special investigations/interventions [25%]) accounted for approximately one-third of delays. Shikder et al.’s study in Bangladesh similarly found that financial/logistical hurdles comprised around 13–14% and pre-op interventions around 23–25% .

Though not directly measured in our cohort, international literature shows increased mortality associated with after-hours or weekend surgeries—the so-called "weekend effect". For certain emergency procedures, mortality risk increases by 11–37% compared to weekday operations.  These underscore broader challenges in staffing and resource allocation outside regular hours.

Evidence supports that addressing system delays can positively impact outcomes. In one retrospective analysis, ensuring early operative interventions significantly reduced in-hospital mortality among EGS patients.  Adoption of structured checklists—like the WHO Surgical Safety Checklist has also offered nearly 40% reduction in 30-day mortality after emergency laparotomy in LMICs.

Delays in emergency surgical care remain a crucial and modifiable determinant of patient outcomes. While system-level constraints like OT availability are the major contributors, patient and disease-related factors also play meaningful roles. Addressing these delays through process optimization, resource allocation, and standardized protocols could significantly lower morbidity and mortality in emergency surgery settings.

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