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Background Level 1 trauma centers are capable of caring for every aspect of injury and contain 24-hour in-house coverage by general surgeons, with prompt availability of nearly all other disciplines upon request. Despite the wide variety of trauma, currently reported protocols often focus on a single surgical service and studies describing their implementation are lacking. The aim of the current study was to characterize all urgent and emergent cases at a large academic Level 1 trauma center, characterize the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on timing of surgery. Methods For this retrospective review, all urgent and emergent cases treated at a single institution, during a 34-month period (January 1, 2015-October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Demographic characteristics for non-elective surgical emergent cases were compiled by level of urgency and operating room (OR) waiting times were compared by year, department, and Level. Results A total of 11,206 urgent and emergent operative cases were included, among over 16 surgical departments. Level 2 cases represented the majority of urgent/emergent cases (33%-36%), followed by Level 3 (25%-26%), Level 1 (21%-22%), Level 4 (12%-16%), and Level 5 (2%-4%). Univariate analysis demonstrated that the proportion of urgent and emergent cases, by level of urgency, did not significantly differ between each year. Operating room waiting time decreased significantly over each year from 2015, 2016, and 2017: 193.40 ± 4.78, 177.20 ± 3.29, and 82.01 ± 2.98 minutes, respectively. Conclusions To the authors' knowledge, this is the first study to characterize all urgent and emergent cases at a large academic Level 1 trauma center, outline the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on surgical waiting times over a 34-month period.