Time-of-day and appendicitis: Impact on management and outcomes

Abstract

Background Observational research has shown that delayed presentation is associated with perforation in appendicitis. Many factors that impact the ability to present for evaluation are influenced by time-of-day; for example, child care, work, transportation, and primary care office hours. Our objective was to evaluate for an association between care processes or clinical outcomes and presentation time. Methods Prospective cohort of 7,548 adults undergoing appendectomy at 56 hospitals across Washington State. Relative to presentation time, patient characteristics, time to surgery, imaging use, negative appendectomy (NA), and perforation were compared using univariate and multivariate methodologies. Results Overall, 63% of patients presented between noon and midnight. More men presented in the morning; however, race, insurance status, co-morbid conditions, and WBC count did not differ by presentation time. Daytime presenters (6AM-6PM) were less likely to undergo imaging (94% vs. 98% p<0.05) and had a nearly 50% decrease in median pre-operative time (6.0h vs. 8.7h p<0.001). Perforation significantly differed by time-of-day. Patients who presented during the workday (9AM-3PM) had a 30% increase in odds of perforation compared to early morning/late night presenters (adjusted OR 1.29, 95%CI 1.05–1.59). NA did not vary by time-of-day. Conclusions Most patients with appendicitis presented in afternoon/evening. Socioeconomic characteristics did not vary with time-of-presentation. Patients who presented during the workday more often had perforated appendicitis compared to those who presented early morning or late night. Processes of care differed (both time-to-surgery and imaging use). Time-of-day is associated with patient outcomes, process of care, and decisions to present for evaluation; this has implications for surgical workforce planning and quality improvement efforts.

Associations between surgical start time (regular vs after hours) and morbidity and mortality during hospitalization in dogs and cats

“…Unfortunately, the retrospective nature of this study prohibits confirmation of this supposition. The time of patient presentation has been found to influence the process of care for human surgical patients 29 . Further investigation of the influence of process of care on feline morbidity associated with emergency surgical intervention is warranted.…”

A protocol for non-operative management of uncomplicated appendicitis

“…Notably, 28% of all patients who failed NOM during admission had a perforation sometime between CT scan and operative exploration, underscoring one of the inherent risks of NOM. Although nighttime admission was not associated with adverse events, there was an association between weekend admission and infectious complications, which may have been influenced by the presence of fewer personnel on weekends and changes in processes of care, as described by Drake et al (19). However, nighttime and weekend admission did not appear to influence protocol compliance.…”

Emergency department patient experience: Same location, same provider, different scores by different survey methods

“…[16] A study conducted with stroke patients found that patients with daytime and nighttime strokes had similar demographics; and another study found that appendicitis patients' clinical, demographic and socioeconomic statuses did not differ between different times-of-presentation. [17,18] Finally, a study conducted in an accident and emergency department found no gender variations in temporal attendance patterns. [19] These fi ndings suggest that demographics are typically similar regardless of when a patient presents to the ED within a 24-hour time period.…”