Purpose Routine preoperative risk assessment (RPRA) using objective risk prediction tools may improve outcomes following Emergency Major Abdominal Surgery (EMAS). This project aims to identify whether the introduction of RPRA as standard of care for EMAS at a regional Victorian hospital has improved postoperative outcomes, improved postoperative Critical Care Unit (CCU) utilisation, and impacted pre-operative palliative decision making. Methodology A retrospective audit was performed of all adult general surgery patients who required EMAS at Bendigo Health between September 2017 and August 2022, including patients planned for surgery who were palliated up-front due to high perioperative risk. Patients requiring surgery for appendicitis, cholecystitis, trauma, and diagnostic laparoscopy were excluded. Outcomes were compared between patients undergoing surgery before and after the introduction of RPRA. Results 691 patients were included in the analysis. Median NELA score was 5. 2.6% of patients were palliated up-front and did not proceed to surgery. Amongst the 673 operative patients, 30-day mortality was 5.2%. Following introduction of RPRA, the operative subgroup saw a significant reduction in unplanned CCU admissions, from 9.14% to 3.48% (p=0.044). There was no significant change in rates of postoperative mortality, severe complications or planned CCU admissions. Conclusion Mortality and complication rates were not significantly reduced following introduction of RPRA. RPRA reduced rates of unplanned CCU admission. RPRA appears useful in guidance of preoperative palliative decision making, however larger, prospective auditing is required to fully assess its utility in this context.