Acute Uncomplicated Appendicitis: Case Time of Day Influences Hospital Length of Stay

Background: Acute appendicitis is the most common surgical infection requiring operative intervention, and length of stay (LOS) typically is short. The timing of emergency appendectomies for acute appendicitis depends on many factors, including anesthesia and operating room availability, staffing, convenience, acuity of illness, and surgeon preference. Efforts to decrease LOS in surgery patients have focused largely on elective operations. We hypothesized that operative time of day would determine when patients were discharged after appendectomy. Methods: Records of patients undergoing appendectomy between July, 2004 and June, 2005 were reviewed retrospectively. Operative date and time, hospital discharge date and time, operative findings, and postoperative complications were reviewed. Hospital LOS was calculated, and the Student t-test used to calculate significance. Results: A total of 199 patients underwent appendectomy during the study period. Twenty-three "outliers," with complicated appendicitis or significant co-morbidities (LOS 4-21 days, 76% perforated), were excluded. Length of stay in uncomplicated appendicitis was influenced significantly by the time of day the operation was performed. Length of stay was shortest if surgery was performed between 0001 and 0400 h (mean LOS 20 h 40 min). In contrast, LOS was 50% greater if the operation was performed during the day (mean LOS 32 h 24 min for cases performed between 0700 and 1500 h). No patients were discharged between 2100 and 0700 h. Surgical site infections occurred in fewer than 5% of patients, and white blood cell count did not predict LOS. Conclusions: Operative time of day was a surprisingly important determinant of hospital LOS. Efforts to minimize LOS and optimize resource utilization should balance operating room availability, surgeon preferences, shift-dependent costs, nursing policies, and hospital systems.