Surgeons’ prioritization of emergency abdominal surgery and its impact on postoperative outcomes

BACKGROUND: Emergency general abdominal surgery (EGS) is associated with high morbidity and mortality. Timely intervention and effective triage systems are crucial to improve outcomes. This study evaluates the impact of surgeons' prioritization and adherence to a triage protocol on postoperative outcomes. METHODS: Single-center retrospective analysis of patients undergoing EGS at Bern University Hospital from 03/2015-12/2022. Patients were categorized into four triage levels based on the urgency of surgery (level 1 within 1 h, level 2 within 6 h, level 3 within 12 h, and level 4 within 24 h). "Protocol violation" was defined in cases where the delay to surgery exceeded the triage level. Primary endpoint included complications according to Clavien-Dindo classification in patients with versus without "protocol violation". RESULTS: A total of 1'947 patients were included. The mean overall delay from admission to surgery was in triage level 1 69.5 ± 127.5 min., in triage level 2 206.5 ± 178.0 min., in triage level 3 350.6 ± 282.6 min. and in triage level 4 693.4 ± 354.8 min.. Triage levels 1 and 2 correlated significantly with increased complication rates compared to triage level 3 and 4 (64% vs. 43% vs. 11% vs. 10%, p < 0.001). Similarly, mortality rates decreased significantly from triage level 1 through 4 (26% vs. 7% vs. 1% vs. 2%, p < 0.001). "Protocol violation" occurred in a total of 13% of patients with decreasing proportions from triage level 1 to 4 (37% vs. 13% vs. 12% vs. 0%, p < 0.001). "Protocol violation" did not statistically affect overall morbidity and mortality in most of the diagnoses. In patients with intestinal ischemia or abdominal abscesses, mortality was significantly higher in patients with "protocol violation". In contrast, in patients suffering from acute inguinal hernias or gastrointestinal bleeding, morbidity was significantly higher in patients without "protocol violation". A significantly shorter hospital length of stay (HLOS) was shown in triage level 2 and triage level 3 when patients were treated without "protocol violation" (8.6 ± 10.0 days vs. 13.5 ± 17.3 days, p = 0.022 and 5.3 ± 8.7 days vs. 6.4 ± 6.7 days, p < 0.001, respectively). CONCLUSION: Surgeons' triage levels significantly correlated with mortality and morbidity. Moreover, "protocol violation" resulted in higher mortality in patients suffering from mesenteric ischemia and abdominal abscesses and resulted in prolonged HLOS. Further incorporating objective parameters into triage decisions in the EGS population may enhance prioritization accuracy, patient safety and resource utilization.