The Long Way to the Operating Room: In‐Hospital Operative Delay and Outcomes in Colorectal Surgery

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Background In‐hospital operative delay may reflect patient complexity and perioperative care processes, but its association with outcomes after colorectal surgery remains incompletely characterized. We evaluated whether surgery after the day of admission identified a clinically distinct subgroup with worse inpatient outcomes and greater resource utilization. Methods Using the Nationwide Inpatient Sample, adults undergoing colorectal surgery following elective hospital admission between 2016 and 2022 were identified. Patients were categorized as same‐day surgery (hospital day 0) or operative delay (surgery after admission). Delay duration was categorized as day 1, days 2–5, and days 6–10. Outcomes included postoperative complications, non‐home discharge, length of stay, in‐hospital mortality, and total hospital charges. Survey‐weighted multivariable models adjusted for patient demographics, socioeconomic factors, transfer status, procedure type, All Patient Refined Diagnosis Related Group severity of illness and risk of mortality, and hospital characteristics. Sensitivity analyses excluded transferred patients, evaluated postoperative length of stay, replaced APR‐DRG measures with individual Elixhauser comorbidities, and assessed robustness to unmeasured confounding using E‐values. Results Among 175,515 patients, 14,336 (8.2%) underwent surgery after admission. Patients with operative delay were older and more frequently had major or extreme illness severity, major or extreme risk of mortality, and interhospital transfer. After adjustment, operative delay was associated with higher probabilities of postoperative complications (14.91% vs. 12.95%; adjusted difference, 1.96 percentage points), non‐home discharge (27.45% vs. 22.25%; adjusted difference, 5.20 percentage points), and in‐hospital mortality (0.78% vs. 0.58%; adjusted difference, 0.19 percentage points), as well as longer length of stay (6.82 vs. 5.01 days; adjusted difference, 1.81 days) and higher total hospital charges ($96,656 vs. $87,823; adjusted difference, $8833). Complications, length of stay, and charges increased across longer delay intervals, with the largest differences after delays of 6–10 days. Conclusions In‐hospital operative delay among adults undergoing colorectal surgery was associated with worse inpatient outcomes and increased resource utilization. Longer total length of stay appeared to reflect hospital days accrued before surgery rather than prolonged postoperative recovery. Operative delay may reflect patient complexity and perioperative care processes although the clinical necessity or modifiability of longer preoperative intervals could not be determined.