INTRODUCTION: The aim of this study was to patient factors associated with increased system time in the management of acute appendicitis at a rural center.METHODS AND PROCEDURES: Retrospective analysis of 378 patients who underwent appendectomies from January 2000 to June 2005 at a rural teaching hospital. Patients undergoing an interval, incidental or negative appendectomy were excluded.RESULTS: The average delay before presentation to emergency department (ED) was 24 hours. It was significantly decreased for adults younger than 45 years (35 vs. 47 hours, P 0.0009), married patients (34 vs. 45 hours, P 0.0089), first examined in hospital ED (30 vs. 57 hours, P 0.0001) and history of fever (36 vs. 45 hours, P 0.0008). In a multivariate regression model initial examination outside of hospital ED (risk ratio 5.3, P <0.005), and lack of peri-umbilical pain (P 0.035) were significant predictors of delay in presentation (adjusted for age, sex, marital status, fever, nausea or vomiting, anorexia, comorbidities, distance and insurance status). The average delay from presentation to surgery was 9.8 hours. It was significantly decreased for patients referred from an outside facility (6 vs. 11 hours P 0.0001), patients with classic presentation (9 vs. 10 hours P 0.0118), or severe appendicitis (9 vs. 10 hours P 0.011), or leading diagnosis of acute appendicitis (9 vs. 16 hours P 0.0014), and no CT scan on admission (11 vs. 8 hours, P 0.0001). In a multivariate regression model leading diagnosis of acute appendicitis (P <0.004) was the only significant predictors for faster time to surgery (adjusted for age, sex, marital status, severity of presentation, comorbidities, and insurance status). CONCLUSION: In a rural population, patients examined in the hospital ED have a significantly shorter overall duration of symptoms before final presentation. Additionally a leading diagnosis of acute appendicitis by the physician is the only variable predictive of decreased time to surgery.