Early Discharge Home Research Articles

Prospective randomized trial of early initiation and hospital discharge on a liquid diet following elective intestinal surgery

Length of hospital stay after elective intestinal surgery may be related to patient tolerance of a diet. We hypothesized that early initiation and discharge home on a clear liquid diet would decrease the length of hospital stay without increasing morbidity. The aim of this study was to determine if early initiation and discharge on a clear liquid diet decreases the length of hospital stay and is safe. Forty-four patients were randomly assigned to either a standard diet or a clear liquid diet. A standard diet (n = 17) was begun after the passage of flatus or stool, and consisted of clear liquids to a volume of approximately 750 ml, then three solid meals, and discharge thereafter. Patients randomized to a clear liquid diet (n = 27) received 30 ml/hr of clear liquids on postoperative day 2, unlimited clear liquids on postoperative day 3, and were dismissed on a clear liquid diet on postoperative day 4. All patients were followed by a daily telephone call and clinic visit. The primary outcome variable was length of hospital stay. The incidence of postoperative intestinal-related sequelae, complications, and readmission rates did not differ between groups. Post-discharge intestinal symptoms were common in both groups but tended to resolve faster in the patients on a standard diet. The length of hospital stay was decreased in the patients on a clear liquid diet compared to those on a standard diet (6.1 ± 1.1 days vs. 4.4 ± 0.2 days; P = 0.09), but total hospital costs did not differ. Early initiation and hospital discharge on a clear liquid diet after elective intestinal surgery decreases the length of hospital stay and is safe.

A Home Visit Program for Breastfeeding Education and Support

A home visit program for breastfeeding education and intervention was developed to provide support for mothers and infants at risk for breastfeeding failure. This program was developed to supplement the Early Discharge Program for mothers and newborns who were discharged within 24 hours of delivery. A breastfeeding assessment tool was developed for use in the hospital and during the early discharge home visit. Home visits are provided by a registered nurse with mother-infant assessment skills and competence to provide breastfeeding education, problem management, emotional support, and referrals to lactation consultants or physicians as needed. The response from patients and physicians has been positive. As the demand for services grew, the program was modified to include other mothers and infants (e.g., those delivering via cesarean and high-risk, preterm, and borderline preterm infants in need of breastfeeding support). The readmission rate for breastfeeding infants who receive a home visit is lower than for infants who do not receive a home visit. Patient satisfaction surveys have been positive.

Stroke units: more trials needed.

Meta-analysis by the Stroke Unit Triallists’ Collaboration [1] of 19 small trials ([2–19] and unpublished data of A. Svensson, P. Harmsen, and L. Wilhelmsen) shows that stroke units reduce mortality and dependency, compared with general medical wards. This may be because better medical management helps prevent fatal complications (e.g. pulmonary emboli, aspiration pneumonia) or because of geographical concentration of patients under multidisciplinary management, led by a trained consultant, where the needs of stroke patients are not overlooked in favour of those of more acutely ill patients [3]. Additional elements (staff training, nurse interest in stroke, education and involvement of carers, earlier onset of physioor occupational therapy) may also have contributed. However, the meta-analysis findings are hard to apply to everyday practice. First, many trials excluded patients still requiring optimal management—those without a hemiparesis or with a mild stroke [3, 4, 8, 9, 12], those with severe strokes [4, 8, 12, 13], a reduced level of consciousness [4, 8, 11, 12, 17], prior disability or stroke [4, 12, 17] and those resident in nursing homes [8, 15, 17]. However, patients without a hemiparesis might still have disabling neglect [20]. Even the mild stroke patient might benefit from early referral to occupational therapy allowing, perhaps, earlier discharge home. Those with severe strokes, which might include many with an initially reduced level of consciousness, benefit from well organized rehabilitation services on ring-fenced wards [14, 21], and about half of these patients, if elderly, might be expected to have additional disabling disorders such as osteoarthritis, dementia and Parkinson’s disease [21]. Mainstream clinical practice is to offer such patients, including those from nursing homes, a course of rehabilitation, as even modest gains (such as the ability to transfer with one instead of two people or to sit in a chair for several hours without falling to the floor) might make all the difference to the possibility of returning home and to quality of life, either at home or in care.

Earlier discharge of infants from neonatal intensive care units: a pilot program of specialized case management and home care. Delaware Valley Child Health Alliance.

A multidisciplinary approach using a neonatology independent physicians association, affiliated hospitals, a pediatric home care company, and a health maintenance organization was designed to promote earlier safe discharge of infants from intensive care. This pilot project involved 43 infants who received case management and early discharge home with home oxygen, monitoring, intravenous antibiotics, gavage feedings, phototherapy, or nutritional management for poor weight gain. A staff neonatologist remained the primary physician until the patient would have been discharged according to standard criteria. Two patients had unscheduled readmissions and all infants survived. This approach resulted in an estimated savings of 456 hospital days and $329,982; 89% of parents rated the care as good to excellent, and 83% were satisfied with the program and outcome. This study suggests that a prospectively designed program can be designed to promote safe earlier discharge of infants in intensive care.

Intrathecal Sufentanil for Extracorporeal Shock Wave Lithotripsy Provides Earlier Discharge of the Outpatient Than Intrathecal Lidocaine

Many anesthetic techniques are currently used for extracorporeal shock wave lithotripsy (ESWL). This randomized, prospective, double-blind study was designed to examine postoperative recovery with two anesthetic techniques for unilateral ESWL; i.e., intrathecal sufentanil versus intrathecal 5% lidocaine. The incidence of adverse effects was also assessed. Twenty-two ASA physical status I-III patients, 18-70 yr of age who were scheduled for unilateral ESWL under spinal anesthesia were studied. Patients were randomized to receive either intrathecal sufentanil 20 microg + saline (n = 11) or intrathecal 5% lidocaine (n = 11) based on their height. Both patients and observers were blinded to the treatment groups. Patients were assessed for intraoperative and postoperative pain via a 10-cm verbal analog pain scale (VAPS) (0 = no pain, 10 = extreme pain). Stone sizes, number of shock waves, and voltages were also compared. The recovery profile-time to ambulate, void, oral intake, and home discharge-was documented. Antiemetic requirements in the postanesthesia care unit (PACU) and incidence of postoperative nausea and vomiting (PONV), pruritus, and sedation were also recorded. This study showed no differences in VAPS between groups at any time in the perioperative period. Patients who received intrathecal sufentanil ambulated (79 +/- 16 vs 146 +/- 57 min mean +/- SD; P < 0.05), voided (80 +/- 18 vs 152 +/- 54 min, P < 0.05), and were discharged home (98 +/- 17 vs 166 +/- 50 min, P < 0.005) significantly sooner than the patients who received intrathecal lidocaine. Although 27% (3 of 11) of the patients who received sufentanil reported pruritus, respiratory depression was not found. There were no differences in PONV between the two groups. Intrathecal sufentanil provided an enhanced recovery profile with significantly earlier home discharge when compared with intrathecal lidocaine. In conclusion, intrathecal sufentanil is a safe and effective method of anesthesia for outpatient unilateral ESWL.

Pantaloon Spica Cast: An Effective Method for Postoperative Immobilization after Free Graft Hypospadias Repair

Purpose We used a postoperative dressing of silicone foam in conjunction with a pantaloon spica cast to optimize the chances for successful graft take in hypospadias repairs with grafts. We compared the results to those of inpatient bed restriction. Materials and Methods A total of 15 patients underwent graft urethroplasty, and application of a penile silicone foam dressing and fiberglass pantaloon spica cast. Patients were discharged home the following morning. Results Two fistulas developed. Results are no different from those of our previously reported cases which required 6 or 7 days of hospitalization. Conclusions We believe that the pantaloon spica cast provides necessary immobilization for facilitating imbibition and inosculation, which are required for graft survival. Also, the spica cast allows early discharge home, obviating the need for prolonged hospitalization and bed rest.

New muscle relaxants for anesthesia during 1-day surgery

In the last few years, the growth of 1-day surgery and the introduction of new techniques have increased the need for general anesthesia with endotracheal intubation and mechanical ventilation. The end point of 1-day anesthesia is early patient discharge home. Therefore, new muscle relaxant agents have been propounded to anesthetists to achieve this. In this paper, we analyze pharmacological and clinical characteristics of available newer muscle relaxants and evaluate their possible use in 1-day surgery.

External Cephalic Version from 34 Weeks under Tocolysis: Factors Influencing Success

External cephalic version (ECV) was performed on 72 patients from 34 weeks of gestation under tocolysis, with ultrasound control and cardiotocograph surveillance. Successful ECV was associated with multiparity, decreased lower segment caesarean section (LSCS) rate, and earlier discharge home. ECV was successful in 51.4% of patients overall, with the success rate being 35% in primigravidas and 71.4% in multiparas (p < 0.005). The LSCS rate was reduced from 91.4% to 0% (p < 0.0001) on comparing the unsuccessful and the successful ECV groups, while breech presentation was reduced from 94.3% to 0% (p < 0.0001). There were no significant fetal complications.

Phototherapy for Neonatal Nonhemolytic Hyperbilirubinemia

Phototherapy, an effective treatment for neonatal indirect hyperbilirubinemia, has guidelines for its initiation but none for its discontinuation. In our study, phototherapy was begun at a mean age of 90 hours in 28 full-term and 30 preterm infants with indirect nonhemolytic hyperbilirubinemia. After three days, phototherapy was halted at a mean bilirubin concentration of 13.0 +/- 0.7 mg/dL in term and 10.7 +/- 1.2 mg/dL in preterm infants, levels higher than those used by other investigators. Bilirubin rebound then occurred at a mean of 12.5 hours to a level of 0.86 +/- 1.0 mg/dL in term and at a mean of 14.1 hours to a level of 0.83 +/- 0.56 mg/dL in preterm infants. No complications were observed nor was there a need for reinstitution of phototherapy. Based on these data, discontinuation of phototherapy at higher bilirubin concentrations and earlier home discharge than previously described appear harmless for both term and preterm neonates.

Controversies in the management of gastroschisis: a study of 40 patients.

Forty infants with gastroschisis were referred to two paediatric surgeons during a 13 year period. Overall survival was 90%. Nine patients were transferred in utero and 31 were referred postnatally. Birth weights, gestational ages, and Apgar scores were similar for both groups. Primary closure of the defect was successfully achieved in seven (78%) patients in the prenatally transferred group compared with 17 (55%) in the postnatal group. Significantly less postoperative assisted ventilation, and a trend in favour of early discharge home, were noted after prenatal transfer. Problems arising during postnatal transfer may have contributed to these differences. No major differences resulting from the mode of delivery were identified. Patients treated by primary closure fared significantly better than those undergoing staged repairs with prosthetic material. Prospective randomised studies are required to confirm these findings.

Early discharge as voluntary and involuntary alternatives to a longer postpartum stay in hospital—effects on mothers' experiences and breast feeding

Due to staff shortages in the maternity department postnatal women had to be discharged from the postnatal wards on the third day post delivery. They were given the option of discharge home on the third day following birth with domiciliary visits from a public health nurse, or transfer to another ward which was staffed by children's nurses. Previously early discharge home had been optional. Using semi-structured interviews over the telephone the effects of 'voluntary' and 'involuntary' early postnatal discharge on women's experiences of early discharge and breast feeding rates were studied in a sample of 230 women. Women discharged 'involuntarily' were more dissatisfied with early discharge and had more problems (e.g. fatigue) than women discharged 'voluntarily'. Early postnatal discharge should remain an option and should not be made compulsory.

Sedation for fibreoptic bronchoscopy: comparison of alfentanil with papaveretum and diazepam

Sedation for fibreoptic bronchoscopy should produce optimal conditions for the operator, patient comfort and rapid recovery allowing early discharge home. We have compared a regimen producing 'light' sedation with a more traditional regimen producing 'deep' sedation. Seventy-six patients undergoing fibreoptic bronchoscopy under topical anaesthesia were randomized to receive either light sedation with the short acting opiate, alfentanil (median dose 1.1 mg, range 0.5-2.6 mg) or deep sedation with a combination of papaveretum (median dose 10 mg, range 5-15 mg) and diazepam (median dose 8 mg, range 0-20 mg). Both techniques gave equally good operating conditions, although patients given alfentanil coughed less than those given papaveretum and diazepam (U = 2.814 P less than 0.01). Patients recorded their degree of apprehension on a visual analogue scale prior to sedation and the actual degree of comfort experienced after recovery. There was no significant difference between apprehension or comfort between the groups. This was despite a higher degree of amnesia for an irrelevant object shown during the bronchoscopy in the deeply sedated group (chi 2 = 21.084 P less than 0.001). Patients given alfentanil performed significantly better in a modified Romberg test (chi 2 = 4.357 P less than 0.05) and a visualisation test (t = 3.035 P less than 0.01) two hours after the bronchoscopy. Alfentanil produced good operating conditions, patient comfort, less cough and a more rapid recovery, compared to the deep sedation regimen, and is an ideal sedative for fibreoptic bronchoscopy.

Which patient education strategies will pay off under prospective pricing?

As cost containment pressures mount under prospective pricing, patient education managers need to assure that appropriate educational strategies are implemented. This article reviews the evidence for nine educational strategies which demonstrate cost-saving potential under prospective pricing: pre-operative education, medication self-administration programs, outpatient education, discharge planning education, family education, peer educators, cooperative care units, early discharge programs and home health programs. Whenever possible, the diagnosis related groups (DRGs) to which these strategies apply are indicated. Finally, issues of patient education and quality of care are discussed.

Early breastfeeding and discharge home for premature infants in bogota, colombia: Kangaroo method

To identify priority areas and practice improvement strategies related to breastfeeding support, in a neonatal intensive care unit (NICU) in Colombia.As part of a quality improvement initiative, this multi-method qualitative descriptive study involved 5 focus group interviews with NICU staff and 6 individual interviews with clinical leaders. Data were complemented by informal conversations with NICU staff and a document review of the hospital's breastfeeding policies and educational materials. Data were analyzed using qualitative content analysis.Priorities for practice improvement included (1) support for milk expression, (2) support for the transition to direct breastfeeding, and (3) creation of policies and tools related to breastfeeding. Findings highlighted ways in which resource limitations influence priority setting to favour the redistribution of existing assets and mobilization of local facilitators for breastfeeding support.Findings will inform the development and implementation of future strategies to enhance breastfeeding support in this unit.

Tricuspid Regurgitation and Acute Myocardial Infarction

A 71-year-old man had a right ventricular infarct complicated with hypotension and transient complete atrioventricular block. The patient was found to have tricuspid regurgitation, which was corrected with a prosthetic tricuspid valve. After correction, there was dramatic improvement in his clinical status, with correction of persistent hypotension and weakness and early discharge home to full activity. Tricuspid regurgitation is a mechanical defect of acute myocardial infarction that benefits greatly from surgical correction. This therapy should be considered in any individual in whom tricuspid regurgitation complicates acute right ventricular infarction.

Experience with subclavian vein for vascular access.

We report our experience with the subclavian vein as a route for temporary vascular access. By modifying the technique described by Uldall one can place these catheters at the bedside without the need of a separate exit tunnel. They are easily maintained in place and allow for early discharge home while awaiting permanent vascular access maturation. The results of approximately 600 dialysis treatments showed adequate clearence with a mean postdialysis drop in creatinine of 5.0mg./dl. and BUN of 46mg./dl. Complication rates were minimal with no hemo or pneumothorax. The rate of complications between bedside and operating room placement was not different. We feel the low complication rate, the ease of insertion, and the patency at home makes this an attractive alternative to other means of temporary dialysis such as: peritoneal dialysis, repeat femoral vein catheterization or arteriovenous shunts.