Improving the Rate of Same-Day Discharge in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery—An Enhanced Recovery After Surgery Quality Improvement Initiative

Abstract

SettingSame-day discharge (SDD) in patients undergoing minimally invasive gynecologic oncology (GO) surgery is a recent trend aligned with Enhanced Recovery After Surgery (ERAS) principles. SDD in GO is safe and feasible based on several recent studies, including a quality improvement (QI) initiative in Edmonton, Alberta, which resulted in SDD rates >70%. PatientsA baseline audit of GO patients at our center (Calgary, Alberta) found the SDD rate to be 14%. Given that Edmonton and our center are within the same province, they have similar patient populations and available resources – suggesting that interventions from the Edmonton QI initiative may be translatable. ObjectivesThe objectives of our QI initiative were: 1) to increase the rate of SDD in eligible GO patients to 70%, and 2) to evaluate the ease with which QI methods demonstrated in one study could be applied at another center. DesignA pre/post-intervention design was used (50 patients/group). InterventionsFour interventions were designed to address root causes for failed SDD identified following QI diagnostics: 1) SDD as the default discharge plan, including a “Day Surgery” surgical booking, 2 & 3) development and implementation of ERAS SDD pre-operative and post-operative order sets, and 4) patient education SDD-specific documents. MeasurementsRate of SDD was measured together with patient demographics and surgical outcomes. Process and balancing measures were defined and tracked. Main ResultsSDD in GO increased from 14% (7/50) to 82% (41/50) after the implementation of the above interventions (OR 28, p<0.0001, 95%CI 9.54-82.11). Improved SDD was achieved without negatively impacting post-operative rates of emergency department visits: 8% pre-, 4% post-intervention within 7 days (OR 0.48, p=0.678, 95%CI 0.09-2.74), 12% pre-, 10% post-intervention within 30 days (OR 0.8148, p=1.0, 95% CI 0.2317-2.86). ConclusionsThis ERAS QI initiative resulted in a substantial increase in SDD in GO, without a negative impact on balancing measures. We demonstrate that the “spread” of simple, clearly defined QI interventions across centers (where the patient population is similar) is feasible. This suggests that an ERAS SDD Program for GO could be a realistic goal for other centers with similar characteristics.