Original article 1
Time delay to surgery for appendicitis: no difference between
surgical assessment unit and emergency department
Helen Schultza, Niels Qvista, Birthe D. Pedersenb and Christian B. Mogensenc
Background In Denmark, emergency departments (EDs)
are replacing acute surgical and medical units. The aim of
this study was to compare the trajectory of patients
undergoing surgery on the suspicion of appendicitis in a
surgical assessment unit (SAU) and EDs with an
observation unit, respectively. The primary outcome
measure was the time from hospital arrival-to-decision for
surgery.
Materials and methods A comparative retrospective
study with a cross-sectional design and a before-and-after
design was carried out during January 2011 to December
2012 at a SAU and an ED at a university hospital (U-SAU
and U-ED) and at an ED at a regional hospital (R-ED). Data
included time of arrival, decision for surgery, surgery and
discharge, and number of blood tests.
Results In total, 250 patients were included. Time to
decision for surgery was 4.50, 4.95, and 4.63 h (P = 0.58) in
the U-SAU, R-ED, and U-ED, respectively. Time from
decision for surgery to start of surgery was 4.60, 3.29, and
4.12 h in the U-SAU, R-ED, and U-ED, respectively. The
difference was significant between the U-SAU and R-ED
(P = 0.05) and between R-ED and U-ED (P = 0.03). Time
Background
In Denmark, a reorganization of the hospital admission of
acute patients through emergency departments (EDs)
has been performed during recent years. The primary
aim was to improve and shorten time to diagnosis and
treatment. To facilitate this, the presence of specialists
from a range of different specialties at the ED was a
prerequisite as emergency medicine is not a recognized
speciality in Denmark. In addition, ED observation units
for patients with a hospital stay of 24–72 h were intro-
duced [1].
Acute abdominal pain is a common reason for referral to
the hospital [2] and might include a time-critical condi-
tion requiring early diagnosis and treatment. Two studies
have investigated the clinical consequences of the reor-
ganization of EDs on this category of patients, showing
that the time from hospital arrival to patient information
about a treatment plan was delayed [3], and the time to
surgery was delayed for patients with acute appendicitis
after introduction of the ED [4]. However, no study has
investigated the entire course from arrival to discharge for
patients with acute abdominal pain.
0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
from surgery to discharge from the hospital was 17.88,
19.28, and 15.13 h in the U-SAU, R-ED, and U-ED,
respectively. The difference was significant between the
EDs (P = 0.02). Significantly more blood tests were
performed in the EDs than in the U-SAU.
Conclusion The introduction of EDs with observation units
did not influence time to decision for surgery, but more
blood tests were performed. European Journal of
Emergency Medicine 00:000–000 Copyright © 2015
Wolters Kluwer Health, Inc. All rights reserved.
European Journal of Emergency Medicine 2015, 00:000–000
Keywords: appendicitis, emergency department,
emergency department observation unit, surgical assessment unit
a
Surgical Department, Odense University Hospital, bResearch Unit of Nursing,
University of Southern Denmark and cEmergency Department, Soenderjylland
Hospital, Aabenraa, Denmark
Correspondence to Helen Schultz, RN, MScN, PhD, Postdoc, Surgical
Department, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C,
Denmark
Tel: + 45 2240 1513; fax: + 45 6591 9872; e-mail: helen.schultz@rsyd.dk
Received 11 June 2015 Accepted 21 September 2015
This study compared the trajectory of patients admitted
with acute abdominal pain, who underwent a diagnostic
laparoscopy on the suspicion of acute appendicitis. The
study was restricted to this group of patients as they
usually require a short hospital stay, have a well-defined
clinical problem, and thus serve as a suitable group for
comparison of different hospital organizations.
The aim was to compare the trajectory of this patient
group in a surgical assessment unit (SAU) at a university
hospital (U-SAU) and a regional hospital ED (R-ED)
with an observation unit in a cross-sectional design and to
compare the trajectory before-and-after implementation
of an ED with an observation unit at the university
hospital (U-ED).
The primary outcome measure was the time from hos-
pital arrival-to-decision for diagnostic laparoscopy, which
was the standard procedure for all patients with sus-
pected acute appendicitis. Secondary outcome measures
were time to be seen by a physician, first administration
of analgesics, time to surgery, number of blood tests and
investigations performed before surgery, length of ED/
SAU stay, length of hospital stay, and readmissions.
DOI: 10.1097/MEJ.0000000000000342
 2 European Journal of Emergency Medicine 2015, Vol 00 No 00

Materials and methods study eligibility, except patients admitted during week-
We carried out a comparative retrospective study with a ends and holidays or referred from other hospitals.
cross-sectional design and a before-and-after design.
The eligible patients were included in the study if they
were referred directly from primary health care service to
Setting
the U-SAU, R-ED, or U-ED, and the patient was at least
The study was carried out in a university hospital and in a
18 years old. Patients who were 15–17 years of age were
regional hospital with a background population for pri-
excluded as they occasionally were referred from the GP
mary referral of ∼ 325 000 and 350 000 inhabitants,
to the pediatric department at the university hospital.
respectively. In Denmark, almost all emergency (non-
The following data from the medical files were regis-
trauma) patients are seen by a GP before hospitalization.
tered: time of arrival, time for first physician (specialist/
The cross-sectional study was carried out in a U-SAU and nonspecialist) note, time to analgesics, time for decision
in an R-ED. for diagnostic laparoscopy, time for diagnostic laparo-
scopy, type and number of blood tests and radiological
The before-and-after study was carried out at the uni-
investigations before surgery, final diagnosis, time for
versity hospital. In 2011, patients with acute abdominal
discharge from the U-SAU, R-ED, and U-ED, time for
pain were admitted directly from the GP to the U-SAU.
discharge from the hospital and readmissions within
In January 2012, the U-SAU was closed and replaced by
30 days after discharge.
the U-ED, who received all acute patients.
Time of arrival was defined in the U-SAU as the time of
The U-SAU received acute patients older than the age of
arrival reported on a U-SAU registration sheet. In R-ED
15 years with abdominal pain and surgical gastrointestinal
and U-ED, it was time of triage. Time of decision for
diseases from Monday to Friday. The R-ED and U-ED
diagnostic laparoscopy was when reported in the medical
received all acute patients of all ages admitted through-
record. Time for diagnostic laparoscopy in the U-SAU
out the week. In all three units, patients with acute
and U-ED was defined as the first note by nurses in the
abdominal pain were only transferred to a surgical ward
operation room as the actual time for laparoscopy was not
when they had a serious illness and if the stay was
documented in the electronic medical file. In R-ED,
expected to be longer than 72 h.
time for laparoscopy was the time reported by the oper-
On average, the U-SAU, R-ED ,and U-ED received 8, ating surgeon. Discharge from the EDs was defined as
30, and 68 acute (nontrauma) patients daily, respectively. discharge from the ED or ED observation unit.
In the R-ED, ∼ 10 were general surgical patients. In the
U-ED, it was ∼ 20 patients. In all three units, there was
Statistical analysis
one nurse for every four patients. In the U-SAU, there
Data were recorded in an Excel database. Time intervals
was a specialist surgeon as the only physician. In R-ED,
between the different actions were calculated and analyzed
there was one junior physician (an internist-trainee) per
in STATA (version 13; StataCorp, Texas, USA). Categorical
eight patients and one surgical specialist on-call. In
variables were compared using the χ2-test or Fisher’s exact
U-ED, there was a specialist surgeon during the daytime.
test if the number was less than 5. Kruskal–Wallis one-way
During the night-time, there was one surgeon in training
analysis was used to compare the continuous variables. All
on-call. In the U-SAU, the patients were seen in order of
continuous data were reported as medians and interquartile
their arrival without any triage and in R-ED in order of
ranges (IQRs) and all categorical data were reported as
their triage score.
absolute numbers and percentage of occurrence. A P-value
of 0.05 or less was considered to be significant.
Data collection
A power calculation was based on the assumption of a
mean time from arrival-to-decision for diagnostic laparo- Ethical considerations
scopy of 300 min. A time difference of 30 min was con- The study was approved by the Danish Data Protection
sidered clinically significant. With an expected SD of Agency (ID: 2010-41-5648) and the Danish Health and
60 min, a power on 80%, and a 95% confidence level, 64 Medicines Authorities (ID: 3-3013-173/1/). In response to
patients were needed in every group or, in total, 192 our request, the Ethics Committee of the Region of
patients. To reach this number of patients, inclusion in Southern Denmark informed that no ethical approval was
the U-SAU was performed from January to December needed (ID: S-20100062).
2011, in R-ED from March to October 2011, and in
U-ED from March to December 2012. Inclusion of
patients in the U-ED started in March to avoid inclusion Results
of patients within the first months after the U-ED had In total, 650 patients were assessed for eligibility and 250
replaced the U-SAU. Medical files of patients of all ages patients were included in the study: 95 from the U-SAU,
with the ICD-10 codes of appendectomy and laparoscopy 76 from R-ED, and 79 from U-ED. Figure 1 shows the
(KJEA00, KJEA01, and KJHA01) were reviewed for reasons for exclusion.

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 Appendicitis in acute care settings Schultz et al. 3

There was no significant difference between the three
groups with respect to age, sex, final diagnosis, and
method of surgery (Table 1). The median age in the
U-SAU, R-ED, and U-ED was 34 years (IQR:
22–51 years), 35 years (IQR: 25–51 years), and 35 years
(IQR: 24–54 years), respectively.
The median waiting times from arrival to different
actions are shown in Table 2. The time from arrival-to-
decision for surgery was similar in the three different
settings. The median waiting time from decision for
surgery to the surgical procedure was 4.60 h (IQR:
2.20–7.38 h), 3.29 h (IQR: 2.10–4.91 h), and 4.12 h (IQR:
2.20–8.72 h) in the U-SAU, R-ED, and U-ED, respec-
tively. Overall, the differences were nonsignificant
(P = 0.07); however, the difference was significant
between the U-SAU and R-ED (P = 0.05) and between
R-ED and U-ED (P = 0.03).
The median time from surgery to discharge from the
hospital was 17.88 h (IQR: 12.08–64.60 h), 19.28 h (IQR:
13.27–81.63 h), and 15.13 h (IQR: 10.00–57.82 h) in the
U-SAU, R-ED, and U-ED, respectively. The difference
was significant between R-ED and U-ED (P = 0.02) only.
Analgesics were provided to 47% in the U-SAU, 50% in
R-ED, and 66% in U-ED, with a significant difference
between R-ED and U-ED (P = 0.03) only.
The percentage of patients being transferred to the sur-
gical ward was 50, 7, and 27% in the U-SAU, R-ED, and
U-ED, respectively (P < 0.01).
More blood tests were performed in R-ED and U-ED
than in the U-SAU, whereas the number of radiological
investigations was similar in the three different settings
(Table 3).
The number of readmissions was 16, 8, and 13 in the
U-SAU, R-ED, and U-ED, respectively, and the differ-
ences were nonsignificant (P = 0.45). The main reasons
for readmissions were pain or infectious complications.
Discussion
This study yielded four major findings. First, there was no
difference in time to decision for surgery between the
three units. Second, patients from R-ED at the district
hospital had a significantly shorter waiting time from
decision for surgery to the start of surgery and a sig-
nificantly longer hospital stay after surgery compared with
the university hospital (U-SAU and U-ED). Third, patients
at the university hospital had significantly more transferrals
between departments during admission than patients at
the district hospital. Fourth, significantly more blood tests
were performed in the EDs compared with the U-SAU.
The equivalent time to decision for surgery in the three
different settings could indicate that time to a treatment
plan for patients with appendicitis was independent of
the organization form. Significantly more blood tests
were performed in the EDs compared with the U-SAU;
however, it did not affect the waiting time. Different
triage strategies between the units did not affect time to
surgery, either did differences in staffing between the
hospitals with surgeons at the front-end at the university

Fig. 1

U-SAU R-ED U-ED

291 assessed for eligibility 169 assessed for eligibility 190 assessed for eligibility

196 excluded: 93 excluded: 111 excluded:

104 (36%) < 18 years 49 (29%) < 18 years 66 (35%) < 18 years
25 through ED 16 transferred from 14 transferred
other unit/hospital, from other unit/
18 transferred planned hospital, planned
from other unit/ appendectomy, appendectomy,
hospital, planned miscoded miscoded
appendectomy,
miscoded
28 (17%) admitted 31 (16%) admitted
49 (17%) admitted during weekend and during weekend
during weekend holiday and holiday
and holiday

n = 95 n = 76 n = 79

Flow chart of inclusion of patients in the three different entities. ED, emergency department; R-ED, Emergency Department, Regional Hospital; U-ED,
Emergency Department, University Hospital; U-SAU, Surgical Assessment Unit, University Hospital.

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 4 European Journal of Emergency Medicine 2015, Vol 00 No 00

Table 1 Characteristics of participants Significantly more patients at U-ED received analgesics

U-SAU a
R-ED b
U-ED c compared with patients from the R-ED. The longer
waiting time to surgery in U-ED than in the R-ED might
Total n (%) n (%) n (%) P-valued
be an explanation for the differences. Another reason
Sex could be differences in the guidelines for administration
Male 59 (62) 37 (49) 36 (46) 0.07
Diagnosis of analgesic.
Appendicitis 63 (66) 56 (74) 62 (78) 0.21
Perforated appendicitis 24 (25) 15 (20) 15 (19) 0.57 Patients in the U-SAU and U-ED were discharged from
Not appendicitis 8 (8) 5 (7) 2 (3) 0.25 the hospital significantly earlier after surgery than
Open surgery
Converted to open surgery 3 (3) 5 (7) 8 (10) 0.16
patients from R-ED. Another study carried out at the
U-SAU and R-ED has shown that patients discharged
a
Surgical Assessment Unit, University Hospital. from the U-SAU did not feel well and were not ready to
b
Emergency Department, Regional Hospital.
c
Emergency Department, University Hospital. go home at the time of discharge [9]. However, the cur-
d
Fisher’s exact test. rent study did not show any difference in terms of
readmissions.
hospital. Improved access to radiological investigations Patients in R-ED had a lower rate of transferral to a
might have had an impact on waiting time; however, only surgical department than patients in the U-SAU and
12–22% of patients underwent radiological investigations. U-ED. The difference in transitions could be explained
by different guidelines for antibiotic treatment in
Waiting time to the start of surgery after decision for patients with perforated appendicitis. In the university
surgery was significantly shorter at the district hospital hospital (U-SAU and U-ED), patients were transferred to
(3.29 h) compared with the university hospital a surgical ward for this treatment. Transitions between
(4.12–4.60 h). The difference between the hospitals hospital units may decrease the safety of the patients.
might be longer than shown in the results as time for start Postoperative patients are especially in need of sufficient
of surgery at the university hospital was the first note of handovers as potential complications of surgery or anes-
nurses at the operation room, whereas it was the sur- thesia must consciously be observed [10].
geon's note for start of surgery at the regional hospital.
Other studies have reported a waiting time from booking The more blood tests performed at the EDs compared
request to start of surgery of 6.6–8.2 h [5–7], which shows with the U-SAU were because of guidelines from the
a relatively low waiting time in the three acute care set- EDs, where all acute surgical patients by routine have
tings in the present study. An explanation for the dif- blood samples taken [11]. A recent study for the surgical
ferences between the units in our study might be department showed that the presence of inflammatory
differences in access to operation rooms between the parameters had no influence on surgeons’ decision-
hospitals. Other studies have shown a shorter waiting making [12].
time to surgery when an increase in the number of Retrospective studies such as ours are subject to hind-
operation rooms was part of the reorganization of the sight bias and limited by the data recorded in the patient
acute care service [7,8]. This indicates that improvement file. Incorrect data in the medical files could be because
of the time course of surgical patients is complex. of delay of documentation, for example, could the time to
Involvement and cooperation with other departments decision for surgery be shorter if there was a delay in time
and services such as access to operation rooms and from surgery request to documentation of the request.
anesthesia might be a means of improving the patient Different routines of documentation at the operation
course. room could have affected the results. Another limitation

Table 2 Waiting time from arrival to occurrence (h)

U-SAUa R-EDb U-EDc

Total Median (interquartile range) Median (interquartile range) Median (interquartile range) P-valued
First doctor 1.38 (1.00–2.58) 1.83 (1.03–2.65) 1.87 (1.15–3.13) 0.21
Analgesics 1.90 (1.08–4.60) 2.05 (0.83–3.80) 1.80 (1.11–3.50) 0.78
Decision for surgery 4.50 (2.53–9.92) 4.95 (2.97–9.97) 4.63 (2.23–9.08) 0.58
Surgery 10.77 (7.15–19.68) 8.79 (6.29–13.73) 10.35 (5.82–17.77) 0.52
Discharge from SAU/ED 21.62 (10.83–29.83) 29.11 (22.18–67.07) 22.47 (15.51–37.20) 0.0001*
Discharge from hospital 33.75 (21.67–76.17) 35.93 (22.48–101.76) 29.27 (19.53–67.13) 0.29

ED, emergency department; SAU, surgical assessment unit.

a
Surgical Assessment Unit, University Hospital.
b
Emergency Department, Regional Hospital.
c
Emergency Department, University Hospital.
d
Fisher’s exact test.
*U-SAU/R-ED (P = 0.0001), U-SAU/U-ED (P = 0.25), R-ED/U-ED (P = 0.0003).

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 Appendicitis in acute care settings Schultz et al. 5

Table 3 Number of blood samples and investigations

U-SAU R-ED U-ED U-SAU/R-ED U-SAU/U-ED R-ED/U-ED Overall
[n (%)] [n (%)] [n (%)] P-valuea P-valuea’' P-valuea P-valuea
Total 95 76 79
Blood samples
Electrolytes, inflammation, and kidney 86 (91) 76 (100) 78 (99) 0.004 0.019 0.51 0.002
function
Liver function 52 (55) 40 (53) 77 (97) 0.45 0.000 0.000 0.000
Coagulation panel 23 (24) 51 (67) 77 (97) 0.000 0.000 0.000 0.000
Blood glucoses 1 (1) 35 (46) 2 (3) 0.000 0.43 0.07 0.000
Others* 19 (20) 23 (30) 15 (19) 0.09 0.51 0.07 0.19
ECG 4 (4) 24 (32) 15 (19) 0.000 0.002 0.05 0.000
Imaging
CT-scan 16 (17) 9 (12) 17 (22) 0.27
Abdominal ultrasonography 8 (8) 5 (7) 8 (10) 0.78
Plain abdominal radiography 0 (0) 6 (8) 0 (0) 0.001
Chest radiography 0 (0) 2 (3) 2 (3) 0.26
Other specialists involved
Gynecologist 5 (5) 3 (4) 9 (11) 0.18
Others 0 (0) 0 (0) 2 (3) 0.19

*For example, pregnancy test, arterial blood gas, and blood culture test.
CT, computed tomography; R-ED, Emergency Department, Regional Hospital; U-ED, Emergency Department, University Hospital; U-SAU, Surgical Assessment Unit,
University Hospital.
a
Fisher’s exact test.

of the study is that the reorganization of the course of Acknowledgements

acute surgical patients included many organizational
changes such as different procedures for triage, categories
of physicians at the hospital front-end, and resources at
the hospitals. Because of the extensive reorganization, it
is not possible to identify all variables that might have an
influence on the results. The study shows the results of
the reorganization overall and not a single change in the
patient pathway.
The study focused on the patient flow during weekdays. It
is unknown how the reorganization affected the patient
flow during weekends, where hospital staffing levels are at
the lowest and acute patients do not have to compete with
elective patients for the resources at the operation room.
Our results have some practical implications. The time to
surgery seems not to be dependent on the U-SAU or ED
organization. However, as the presurgery time was sig-
nificantly shorter and postsurgery care was longer in the
district hospital, both hospitals might be able to achieve
further time reduction in the overall length of stay by
reassessing their routines. The number of blood tests and
transferrals between departments might be reduced by re-
evaluating the standard requests for analysis and the policy
of administration of antibiotics to this group of patients.
Conclusion
The introduction of an U-ED had no significant influ-
ence on the hospital course for patients with acute
appendicitis, but significantly more blood samples were
taken. We found no arrival-to-decision for surgery time
differences between the R-ED and the U-SAU or U-ED.
The effects on the quality of the treatment and costs are
unknown.
This study was funded by University of Southern
Denmark, Odense University Hospital, and Novo
Nordisk Foundation.
Conflicts of interest
There are no conflicts of interest.
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