gms | German Medical Science

Objectives: Emergency and surgery for acute injuries is often required to avoid excessive bleeding and prevent from infections in open fractures. However, it has previously been discussed, that surgeon related factors (e.g. experience of the surgeon, teaching vs. non-teaching hospital) might play a role in adverse outcomes for these surgeries. Is the time of day for emergent surgery associated with complications?

Methods: A prospective database (AQC, nationwide Swiss quality assurance project) was used to evaluate all trauma surgeries within 11 years in more than 70 Swiss surgical units. Inclusion criteria: All trauma coded diagnosis that were surgically treated in Swiss hospitals. Exclusion criteria: missing data for time of surgery. The daytime of surgery was stratified into morning (7AM - noon), afternoon (1PM - 6PM), evening (7PM - 11PM) and night (Midnight - 6AM). The primary outcomes were intraoperative (e.g., nerve, tendon, or vascular damage, iatrogenic fractures), postoperative (e.g., bleeding, infection, impaired wound healing, incorrect axial, rotational or length reduction) and general complications (pulmonary, cardiovascular, gastrointestinal, renal, or neurological) and mortality. Co-factors included age, gender, ASA classification, type of surgery, experience of the surgeon, length of surgery and length of stay)

Statistics: Mean and standard deviation expressed continuous data, frequencies and percentage expressed dichotomous data. For statistical analyses, we performed unpaired t-tests and Pearson's chi-squared tests or Fisher's exact test if minimum expected cell frequency was less than five. Significant or nearly significant variables (p<0.10) were sought in multivariate analysis (binary logistic regression analysis). A p-value of < 0.05 was considered statistically significant.

Results and conclusion: Of 31'692 patients, 44% were operated in the morning, 40% in the afternoon, 14% in the evening and 1.7% at night. The in-hospital mortality rate was significantly higher after nightly (2.4%) as well as afternoon surgery (1.7%). The time of surgery had no significant influence on intra- (0.5%) or postoperative complication rates (3.4%) in multivariable analysis, but a significant influence on general complications (7.9%). Afternoon- and night-surgery were significant predictors for general complications. Age, gender, higher ASA classification, and emergency procedures were typical risk factors for mortality and complications in this cohort.

Emergency procedures performed at night and in the afternoon appears to be associated with an increased incidence of adverse outcomes. Further studies should evaluate whether this is relevant for certain diagnoses and/or procedures.