Las Vegas—Researchers have shown that with each day that patients wait in the hospital secondary to a delay in their elective surgery, they experience a significant increase in risk for infectious complications.

In a study presented at the 2010 annual meeting of the Surgical Infection Society, patients had markedly higher rates of all nosocomial infections after coronary artery bypass graft (CABG) surgery, colon resection and lung resection if they had an in-hospital delay in surgery of just one day. With each day, risk for infection grew, particularly urinary tract infection and pneumonia.

“It’s important to realize as physicians that when elective surgical cases are delayed and the patients remain in the hospital, there is a significant impact on things other than cost,” said lead author Todd R. Vogel, MD, MPH, assistant professor of surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, N.J.

“Patients overall are being set up for infectious complications and a higher risk of mortality from an infectious standpoint. We need to be cognizant of that and find methods to decrease in-hospital delay of elective procedures, especially for CABG, where almost half of these patients experienced delay.”

Dr. Vogel and his colleagues set out to investigate whether in-hospital delays in elective surgery put patients at greater risk for infectious complications.

The study focused on adults older than 40 years of age who underwent elective CABG, colon resection and lung resection. Using data from the National Inpatient Sample for 2003 to 2007, investigators identified more than 163,000 procedures that met study criteria.

For all three procedures, the rates of infection increased incrementally with each day of delay.

The effect was greatest among patients who underwent CABG surgery. Almost half of these patients (47%) experienced an in-hospital delay before their surgery. Infections occurred in 5.73% of patients who were operated as scheduled, and rose to 6.68% with a one-day delay, 9.33% with a two- to five-day delay and 18.24% with a six- to 10-day delay. In patients who had delays for more than one week, the adjusted odds ratio for an infectious complication was 2.6.

There was also an increased cost associated with the delayed procedures. Total costs related to CABG rose from $25,164 when patients were operated on the first day to more than $42,000 with a delay of six to 10 days.

Delays were less common among patients undergoing colon and lung resections. For patients who had colon resection, 20% were delayed at least one day. Infection rates were 8.43% when surgery went as scheduled, 11.86% with a one-day delay, 15.79% with a two- to five-day delay and peaked at 20.56% when there was a six- to 10-day delay.

The adjusted odds ratio of developing an infection after an in-hospital delay for these surgeries was 1.4 after one day, 1.7 after two to five days and 2.5 after six days.

Hospital costs, too, rose with each delay. Costs averaged $13,660±$12,268 with no delay, increased by $3,770 after one day, increased another $3,587 after two to five days and totaled $25,307±$19,869 with a six- to 10-day delay.

Patients having lung resection experienced a smaller but still significant rise in infection rates. With infections reported in 10.17% of non-delayed patients, the rates rose to 14.53% after one day, 15.53% after two to five days and 21.62% after six to 10 days.

The costs increased with each delay: from $18,519 with no delay, to $22,159, $22,656 and $25,054, respectively. All of the increases were significant (P<0.0001). Only 5% of lung resection patients experienced a delay of one day or longer.

“The study highlights that it’s important for surgeons to do what we can to prevent delays, and future root analysis will be needed on an institution-by-institution level,” said Dr. Vogel.

“We need to consider how long these people should sit around the hospital before elective cases are done. If they are true elective cases, maybe we should look at sending people home.”

However, the study has some important limitations, said other surgeons. Most significantly, it failed to address the causes for the delays. The delays might have been caused by patient comorbidities that would also increase their susceptibility to infectious complications, although the investigators did account for patient comorbidities.

“How do we know that these delays are preventable?” asked E. Patchen Dellinger, MD, professor of surgery, University of Washington, Seattle.

Michael West, MD, PhD, professor and vice chair of the University of California, San Francisco Department of Surgery and chief of surgery at San Francisco General Hospital, said the results are impressive, despite the study’s retrospective design.

“The authors did their best to control for many variables and the impact of delay to operation persisted, so the results are very provocative,” he said.

He said more studies are needed to look deeper into the causes for surgical delays. The delays had little impact on rates of surgical site infection, but markedly increased rates of urinary tract infection and pneumonia, particularly in CABG patients, he noted.

“While it does behoove us to try to minimize delays, and in the process save money, any interventions to impact this really have to take everything into account,” Dr. West said.