LIMB NECROTIZING FASCIITIS AND TIME TO DEFINITIVE MANAGEMENT: A TEN-YEAR COHORT

Necrotising fasciitis (NF) is a time critical surgical emergency which is difficult to diagnose early, with delays resulting in higher rates of mortality and morbidity. We reviewed all cases where NF was considered as a differential diagnosis, presenting over a decade from January 2015 to January 2025, from our population of 800,000. The cohort was identified from NHS Lothian electronic health records and cross-checked with Public Health Scotland. There were 47 confirmed cases (60% male; mean age 52±15 years). Most patients (64%) were from areas of high economic disadvantage (SIMD quintiles 1–2). Patients were stratified by time to surgery from admission: early (≤12 hours; n=28) vs. delayed (>12 hours; n=19). The delayed group had increased rates of diabetes (53% vs. 18%; p=0.02) and higher initial systolic blood pressure (118 vs. 100 mmHg; p=0.045). All other admission characteristics were comparable. Delayed surgery was associated with increased 30-day mortality (21% vs. 14%; p=0.57) and amputation rates (37% vs. 25%; p<0.001). Median time from presentation to theatre was 8.6 hours (range 3.0–111.4). Pathway analysis identified two critical delays: presentation to clinical suspicion (median 4.3 hours, range 0.8–104.0) and surgical referral to theatre (median 4.2 hours, range 1.1–13.3). Initial misdiagnosis occurred in 40% of patients, associated with additional delay to theatre of 17.9 hours (p<0.001). Hospital transfers were required in 19% of cases, further delaying time to theatre by 1.8 hours (p=0.028). This study demonstrates that surgical delays in NF correlate with poorer outcomes and identifies specific pathway bottlenecks for quality improvement initiatives.