Comprehensive perioperative care program to improve same-day discharge after minimally invasive gynecologic oncology surgery (MIGOS)

Abstract

<h3>Objectives:</h3> Same-day discharge (SDD) after minimally invasive hysterectomy for benign or malignant gynecologic conditions has been shown to be safe and feasible, but remains challenging to implement. We designed and implemented a quality improvement perioperative program for minimally invasive gynecologic oncology surgery (MIGOS). Our aim was to improve SDD rate from 30% to 75% over the study period, while maintaining acceptable 30-day perioperative outcomes and patient experience. <h3>Methods:</h3> Consecutive patients undergoing minimally invasive hysterectomy at a single cancer centre were included during the 9-month project period and a historical cohort of 100 consecutive patients was identified for comparison. A team of gynecologic oncologists, anesthesiologists, and nurses developed a comprehensive perioperative care program and met bi-weekly to revise interventions through plan-do-study-act (PDSA) cycles. Patients were followed for 30 days after discharge. We conducted a descriptive analysis of the characteristics of pre-MIGOS and MIGOS patient cohorts using Wilcoxon rank-sum or Fisher exact tests. We used a run chart to monitor effects of interventions on outcomes and a pre-post analysis to evaluate for statistical significance of change in SDD and perioperative outcomes. <h3>Results:</h3> We assessed 100 consecutive pre-MIGOS and 79 consecutive MIGOS patients. Overall SDD rates increased from 31% (31/100) to 71% (56/79) after implementation (p<0.001) (Figure 1). There was a consistent increase in SDD rate after implementation, although more pronounced following the start of the COVID pandemic. The MIGOS cohort was significantly younger (59 vs. 65; p=0.04) and had shorter operative times (168 vs. 202 minutes; p<0.001) but the two groups were not different with respect to BMI, comorbidity, stage distribution, type of procedure performed, and intraoperative blood loss. We found no difference in 30-day perioperative complication rates, readmission, reoperation, clinic visits, emergency department visits, mortality or morbidity. The most common reason for overnight admission was nausea and vomiting (35%), complications related to pre-existing comorbidities (15%) and urinary retention (10%). Overall, 89% of MIGOS patients rated their experience as ‘very good' or ‘excellent', and 87% felt that their post-operative length of stay was adequate. <h3>Conclusions:</h3> Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, a multidisciplinary team significantly improved SDD rates while maintaining low 30-day perioperative complications and excellent patient experience.