Expedited Discharge Research Articles

Determining factors influencing hospital stay for individuals admitted with DKA – findings from DEKODE length of stay QIP.

There are significant variations in discharge post-diabetes-related ketoacidosis (DKA) hospitalisation, yet there is a paucity of research to understand or minimise the reasons. This Quality Improvement Project (QIP) aimed to identify reasons for post-DKA discharge delays and assess intervention efficacy. Utilising the Digital Evaluation of Ketosis and Other Diabetes-related Emergencies (DEKODE) model, data from 177 DKA episodes from January 2021 to July 2023 across three hospitals were analysed. Factors affecting discharge were investigated through a Plan-Do-Study-Act (PDSA) methodology. While interventions focused on optimising data collection and refining discharge guidelines, no significant reduction in DKA duration or length of stay was observed. Findings highlight post-DKA hospitalisation's multifaceted nature and the limited impact of simple interventions. Collaborative efforts and further research are necessary to develop effective strategies for expedited discharge and improved patient care. This study's comprehensive tracking and analysis tool offers valuable insights for future interventions in managing DKA-related hospitalisations.

Readmission Rates After Expedited Postpartum Discharge.

To characterize national trends in expedited postpartum discharge and, secondarily, to identify predictors of expedited postpartum discharge and assess whether expedited postpartum discharge was associated with postpartum readmissions within 60 days of delivery hospitalization discharge. Birth hospitalizations and subsequent 60-day postpartum readmissions were extracted from the 2016-2020 Nationwide Readmissions Database for this retrospective cohort study. Postpartum discharge was categorized as expedited (less than 2 days after vaginal birth or less than 3 days after cesarean birth), routine (2 days after vaginal birth or 3 days after cesarean birth), or prolonged (more than 2 days after vaginal birth or more than 3 days after cesarean birth). Trends in expedited discharge were assessed over the study period with joinpoint regression. Unadjusted and adjusted logistic regression models were performed to assess clinical, hospital, and demographic predictors of expedited postpartum discharge. Sixty-day postpartum readmission risk was calculated, and adjusted regression models were performed to evaluate the association between expedited postpartum discharge and readmission. Of 17.9 million birth hospitalizations, 32.9% had expedited postpartum discharge. The overall 60-day postpartum readmission rate after delivery hospitalization discharge was 1.7% for all patients, 1.4% for expedited postpartum discharge, 1.6% for routine discharge, and 3.3% for prolonged discharge. Rates of expedited postpartum increased from 29.1% in 2016 to 31.4% in 2019 and to 43.8% in 2020. This trend was not significant (average annual percent change: 9.9%, 95% CI, -1.6% to 23.7%), although rates of expedited discharge were significantly higher in 2020 than in 2016-2019 ( P <.01). Younger and older age, chronic comorbid conditions, mental health conditions, and obstetric complications (eg, transfusion, chorioamnionitis or endometritis) were associated with lower likelihood of expedited postpartum discharge. Expedited postpartum discharge was associated with 14% lower adjusted odds of 60-day postpartum readmission compared with routine discharge (adjusted odds ratio 0.86, 95% CI, 0.85-0.88). Rates of expedited postpartum discharge increased significantly in 2020 compared with 2016-2019 and were not associated with 60-day postpartum readmission. These findings suggest that broader use of expedited postpartum discharge has not resulted in increased risk of postpartum readmissions.

Expedited versus standard postpartum discharge in patients with hypertensive disorders of pregnancy and its effect on the postpartum course

BackgroundHospital stay after an uncomplicated delivery is typically 2 days for vaginal birth and 3 days for cesarean birth. Health maintenance organizations and third-party payers have encouraged shorter maternity stays. The safety of earlier discharge is unclear particularly when it comes to patients diagnosed with hypertensive disorders of pregnancy (HDP). ObjectiveTo examine whether expedited discharge amongst patients with HDP will have a negative effect on postpartum readmission rate and blood pressure related complications. Study designThis was a single academic center retrospective cohort study of patients with HDP (gestational hypertension, preeclampsia, or chronic hypertension) for 2 epochs: 2015–2018, prior to implementation of an expedited discharge policy, and 2019–2020 after hospital wide implementation of expedited postpartum discharge. The expedited discharge policy entailed patients being discharged home as soon as day 1 after a vaginal delivery and day 2 after a cesarean delivery. The primary outcome was unplanned health care utilization postpartum, defined as emergency department (ED) visits, unscheduled clinic visits, and hospital readmission. Secondary outcomes were planned postpartum visits attendance, antihypertensive medication initiation after discharge, and blood pressure control throughout the first year. Bivariable and multivariable logistic regression analyses were run to evaluate the association between expedited discharge and primary and secondary outcomes. ResultsA total of 1,441 patients were included in the analysis. There were no statistically significant differences in the rate of unplanned health care utilization (11.3% in the standard postpartum discharge group vs. 13.8% in the expedited discharge group, P=.17). Systolic and diastolic blood pressures did not differ between the groups at 1–2 weeks, six weeks, and one year postpartum. Patients in the expedited discharge group were more likely to attend the 1–2-week postpartum blood pressure check (58.7% vs. 51.7%, P=.02, adjusted OR 1.33, 95% CI 1.08–1.77). Other secondary outcomes did not differ between the two cohort groups. ConclusionIn this single academic center study, expedited discharge after delivery in patients with HDP was not associated with a higher rate of unplanned healthcare utilization postpartum.

Trends in Hospital Stay, Complication Rate, and Mortality in Hip Fracture Patients: A Two-Decade Comparison at a National Tertiary Referral Center.

Background: Since the turn of the century, the age-adjusted incidence of proximal femoral fractures has caused a plateau or fall. However, it was anticipated that the number of patients with proximal femoral fractures would rise as life expectancy rose and the population over 80 years old expanded. The aim of this study was to compare the length of hospital stay, complication rate, and mortality in patients with proximal femoral fractures between two different time periods: 20 years ago and the present. Methods: We conducted a retrospective review of medical records of patients aged 65 years and above who underwent surgery for proximal femoral fractures between January 2000 and December 2001 and between January 2020 and December 2021. We collected information on age, gender, fracture type, length of hospital stay, and complication rate. Dates of death were obtained from the Ministry of the Interior and Safety. Results: We included 136 patients who were operated on between 2000 and 2001 and 134 patients between 2020 and 2021. The average age increased significantly from 71.6 years to 79.0 years (p < 0.001). The length of hospital stay decreased dramatically from 15.1 days to 6.0 days (p < 0.001). There was no statistically significant difference in delirium, urinary tract infection, or pneumonia. No difference was found in 30-day or 1-year mortality between the two groups. Conclusions: The complication rate and mortality between the two time periods appeared comparable, although the length of hospital stay decreased substantially. Therefore, we recommend considering expedited discharge from the acute care hospital for elderly hip fracture patients while implementing an individualized approach for better outcomes.

Single-Operator Left atrial appendage Occlusion utilizing Conscious sedation TEE, Lack of Outpatient pre-imaging, and Same-day Expedited discharge (SOLO-CLOSE): A comparison with conventional approach.

Left atrial appendage occlusion (LAAO) with WATCHMAN currently requires preprocedural imaging, general anesthesia, and inpatient overnight admission. We sought to facilitate simplification of LAAO. We describe and compare SOLO-CLOSE (single-operator LAA occlusion utilizing conscious sedation TEE, lack of outpatient pre-imaging, and same-day expedited discharge) with the conventional approach (CA). A single-center retrospective analysis of 163 patients undergoing LAAO between January 2017 and April 2022 was conducted. The SOLO-CLOSE protocol was enacted on December 1, 2020. Before this date,we utilized the CA. The primary efficacy endpoint was defined as successful LAAO with ≤5 mm peri-device leak at time of closure. The primary safety endpoint was the composite incidence of all-cause deaths, any cerebrovascular accident (CVA), device embolization, pericardial effusion, or major postprocedure bleeding within 7 days of the index procedure. Procedure times, 7-day readmission rates, and cost analytics were collected as well. Baseline characteristics were similar in both cohorts. Congestive heart failure (37.5% vs. 11.1%) and malignancy (28.8% vs. 12.5%) were higher in SOLO-CLOSE. Median CHA2D2SVASc score was 5 in both cohorts. The primary efficacy endpoint was met 100% in both cohorts. Primary safety endpoint was similar between cohorts (p = 0.078). Mean procedure time was 30 min shorter in SOLO-CLOSE (p < 0.01). Seven-day readmissions for SOLO-CLOSE was zero. After SOLO-CLOSE implementation, there was a 188% increase in positive contribution margin per case. The SOLO-CLOSE methodology offers similar efficacy and safety when compared to the CA, while improving clinical efficiency, reducing procedural times, and increasing economic benefit.

National outcomes of expedited discharge following esophagectomy for malignancy.

Expedited discharge following esophagectomy is controversial due to concerns for higher readmissions and financial burden. The present study aimed to evaluate the association of expedited discharge with hospitalization costs and unplanned readmissions following esophagectomy for malignant lesions. Adults undergoing elective esophagectomy for cancer were identified in the 2014-2019 Nationwide Readmissions Database. Patients discharged by postoperative day 7 were considered Expedited and others as Routine. Patients who did not survive to discharge or had major perioperative complications were excluded. Multivariable regression models were constructed to assess association of expedited discharge with index hospitalization costs as well as 30- and 90-day non-elective readmissions. Of 9,886 patients who met study criteria, 34.6% comprised the Expedited cohort. After adjustment, female sex (adjusted odds ratio [AOR] 0.71, p = 0.001) and increasing Elixhauser Comorbidity Index (AOR 0.88/point, p<0.001) were associated with lower odds of expedited discharge, while laparoscopic (AOR 1.63, p<0.001, Ref: open) and robotic (AOR 1.67, p = 0.003, Ref: open) approach were linked to greater likelihood. Patients at centers in the highest-tertile of minimally invasive esophagectomy volume had increased odds of expedited discharge (AOR 1.52, p = 0.025, Ref: lowest-tertile). On multivariable analysis, expedited discharge was independently associated with an $8,300 reduction in hospitalization costs. Notably, expedited discharge was associated with similar odds of 30-day (AOR 1.10, p = 0.40) and 90-day (AOR 0.90, p = 0.70) unplanned readmissions. Expedited discharge after esophagectomy was associated with decreased costs and unaltered readmissions. Prospective studies are necessary to robustly evaluate whether expedited discharge is appropriate for select patients undergoing esophagectomy.

Outcomes of an expedited same-day discharge protocol following cardiac implantable electronic device (CIED) implantation.

With increasing constraints on healthcare resources, greater attention is being focused on improved resource utilization. Prior studies have demonstrated safety of same-day discharge following CIED implantation but arelimited by vague protocols with long observation periods. In this study, we evaluate the safety of an expedited 2hour same-day discharge protocol following CIED implantation. Patients undergoing CIED implantation at three centers between 2015 and 2021 were included. Procedural, demographic, and adverse event data were abstracted from the electronic health record. Patients were divided into same-day discharge (SDD) and delayed discharge (DD) cohorts. The primary outcome was complications including lead malfunction requiring revision, pneumothorax, hemothorax, lead dislodgement, lead perforation with tamponade, and mortality within 30days of procedure. Outcomes were compared between the two cohorts using the χ2 test. A total of 4543 CIED implantation procedures were included with 1557 patients (34%) in the SDD cohort. SDD patients were comparatively younger, were more likely to be male, and had fewer comorbidities than DD patients. Among SDD patients, the mean time to post-operative chest X-ray was 2.6h. SDD had lower rates of complications (1.3% vs 2.1%, p = 0.0487) and acute care utilization post-discharge (9.6% vs 14.0%, p < 0.0001). There was no difference in the 90-day infection rate between the cohorts. An expedited 2hour same-day discharge protocol is safe and effective with low rates of complications, infection, and post-operative acute care utilization.

Enhanced recovery after surgery (ERAS) protocol reduces need for patient selection for day surgery total knee arthroplasty

IntroductionThis study explored the safety and efficacy of Enhanced Recovery After Surgery (ERAS) together with a Day-surgery protocol on some commonly used selection criteria for expedited discharge after Total Knee Arthroplasty (TKA). MethodsERAS Day surgery TKA performed between Aug 2020 to July 2021 were included in this study. Discharge within 24 h was considered passing protocol. Complications such as infection, re-admission, and re-operation within 30-days were recorded. Patient demographics, medical comorbidities, and outcome measures at 6-month post-operatively were analysed between those who were successfully discharged within 24 h and those with prolong admission. ResultsA total of 342 patients were included in the study. 315 patients (92.1 %) were discharged within 24 h s. Inadequately controlled pain was the most common reason for delayed discharge (17.9 %). No statistically significant difference in gender, age, Charlson Comorbidity Index (CCI), Body Mass Index (BMI), and American Society of Anaesthesiologist Classification (ASA) were noted between patients who failed protocol and those who passed. Readmission rate within 30days was 2.6 %. Infection occurred in 5 cases, including 2 prosthetic joint infection (PJI) requiring debridement, antibiotics, and implant retention (DAIR), 2 surgical site infection treated with antibiotics, and 1 pneumonia. No 30-days complication occurred in patients who initially failed ERAS Day-surgery protocol. Binary logistic regression was statistically insignificant on effect of gender, age, CCI, BMI, and ASA on passing protocol or 30-days complications. Propensity score matching of patients with prolong stay of more than 24 h did not demonstrate any difference in 6-month outcome. ConclusionPatient characteristics such as gender, age, CCI, BMI, and ASA did not influence successful completion of ERAS Day-surgery protocol. Even if patients were initially enrolled in ERAS Day-surgery protocol but failed to be discharged within 24 h, this did not predispose them to increased 30-days complication or poorer 6-month outcome. Level of evidenceIII.

Abstract P211: Expedited Versus Standard Postpartum Discharge In Patients With Hypertensive Disorders Of Pregnancy

Background: A hospital stay after an uncomplicated delivery is ~2 days for vaginal birth and ~3 days for cesarean birth. Hospitals and third-party payers have encouraged shorter maternity stays. The safety of earlier discharge is unclear particularly when it comes to patients with hypertensive disorders of pregnancy (HDP). Our aim was to examine whether expedited discharge (1 day after vaginal and 2 days after cesarean birth) has a negative effect on postpartum course and BP after HDP. Methods: A retrospective cohort study of patients with HDP (gestational hypertension, preeclampsia, chronic hypertension) during 2 epochs: 2015-2018, prior to implementation of expedited discharge, and 2019-2020, after implementation of expedited postpartum discharge. The primary outcome was unplanned health care utilization postpartum, defined as emergency room (ER) visits, clinic visits, and hospital readmission. Secondary outcomes were planned postpartum visit attendance and BP control during the 1st year. Bivariate and multiple logistic and linear regressions were run to evaluate the association between expedited discharge and study outcomes. Results: A total of 1441 patients were analyzed. There were no differences in ER or clinic visits or readmission for BP between expedited and standard postpartum discharge (table). Systolic and diastolic BP at 1-2 weeks, 6 weeks, and 1 year postpartum were similar in both groups. Expedited discharge was associated with higher likelihood of attending BP check at 1-2 weeks postpartum (aOR 1.33, 95% CI 1.08-1.77). Conclusion: Expedited discharge after HDP was not associated with BP complications or unplanned healthcare utilization postpartum.

Association of postoperative length of stay with outcomes following orthotopic heart transplantation-A national analysis.

In the absence of standardized recovery protocols, there is little evidence to guide postoperative care to ensure optimal in-hospital and long-term outcomes following heart transplantation (HT). Using two national databases, we examined the association between postoperative length of stay (LOS) with patient/graft survival, index hospitalization costs, and non-elective readmissions. Adult HT recipients from 2010 to 2019 were identified and analyzed within the Organ Procurement and Transplantation Network (OPTN) Database and Nationwide Readmissions Database (NRD). The risk-adjusted relationship between 1-year mortality and LOS was assessed with restricted cubic splines and subsequently used to stratify patients into Expedited (7-11 days), Routine (12-16 days), and Delayed (>16) discharge groups. Survival outcomes were analyzed using Restricted Means Survival Time analysis (RMST) and multivariable Cox models. Of 9995 HT recipients within the OPTN, 3777 (38%) were categorized as Expedited, and 3040 (30%) as Routine. After adjustment, expedited discharge was not associated with inferior 90-day (ΔRMST -.01, p=.91) and 1-year patient survival (ΔRMST -.02, p=.53). Additionally, expedited was not associated with increased odds of non-elective readmission at 90-days (HR 1.04, CI .77-1.43) relative to Routine discharge. Counterfactual analysis revealed an estimated cost saving of $50 million if all Routine patients received an expedited discharge. Expedited discharge after HT seems to be cost-effective and is not associated with inferior outcomes. Institutional-level outcome analyses should be performed to identify patients that would benefit from expedited discharge, and future studies should analyze the feasibility of implementing standardized discharge protocols following HT.

PO-03-051 EXPEDITED SAME DAY DISCHARGE PROTOCOL IS SAFE FOR PATIENTS UNDERGOING CARDIAC IMPLANTABLE ELECTRONIC DEVICE (CIED) IMPLANTATION

Prior studies have demonstrated the safety of same day discharge in appropriately selected patients undergoing CIED implantation though a limitation is the requirement for prolonged post-operative observation. There is limited data on whether expedited discharge pathways, which can reduce post-operative resource utilization, can offer comparably safe outcomes. To evaluate outcomes of an expedited same day discharge (SDD) protocol across the hospitals. All patients undergoing pacemaker and ICD implantation between 2018-2021 at three hospitals were identified. The post-operative pathway for SDD included a two-hour (1) PA/lateral chest x-ray (2) device interrogation including set up for remote monitoring and (3) bedside evaluation. This protocol was implemented over the study period and use was at physician discretion. Patients’ sociodemographics, comorbidities, and procedure were retrospectively collected. Outcomes included 30-days post-implant unplanned healthcare utilization (urgent care, emergency department, or hospital visits) as well as 90-day infections. Differences between SDD versus not same day discharge patients were assessed using chi-square test for categorical variables and t-test for continuous variables. Multivariate logistic regression analysis was used to evaluate the association between discharge grouping and outcomes of interest. Between 2018-2021, 4872 patients underwent CIED implantation and 28.3% were discharged same day. As summarized in Table 1, compared to SDD, patients not discharged on the same day were older, more likely to be female, and had a higher incidence of comorbidities including hypertension, diabetes mellitus, stroke, and heart failure. Among patients discharged on the same day, the mean time to chest x-ray post-operatively was 2.8 (SD±1.8) hours. Adjusting for the baseline characteristics, SDD patients had signficantly lower 30-day unplanned healthcare utilization (AOR: 0.49 95%CI: 0.40-0.59), complications (AOR: 0.60 95%CI: 0.38-0.93) and mortality (AOR: 0.19 95%CI: 0.06-0.62). Additionally, 90-day infection rates were not significantly different based on discharge grouping. An expedited SDD protocol using a two-hour post-implant evaluation protocol in appropriately selected patients appears to be safe without an increase in adverse events compared to patients hospitalized post-operatively for extended observation. Further investigation to define patient selection criteria is warranted.

Healing at Home: Impacting Postpartum Outcomes Utilizing Clinical Practice Changes and Augmented Intelligence [ID: 1379350

INTRODUCTION: The fourth trimester is a time of great physical and emotional challenge. To help patients navigate this period, we created the Healing at Home (H@H) program, which combined expedited discharge with a 24/7 bidirectional postpartum support chatbot. METHODS: Clinical outcomes, abstracted from medical record and patient report via text message, were evaluated for patients enrolled in H@H (March 2020 to September 2021) compared to patients delivering prior to program implementation (July to December 2019). Enrolled patients had a full-term singleton vaginal delivery of a non-small-for-gestational-age infant without postpartum hemorrhage (&gt;1,000 cc), a low-risk sepsis risk score, a low- to intermediate-risk bilirubin, and lack of significant maternal comorbidities (eg, preeclampsia, preexisting diabetes). Institutional review board waiver for this quality improvement study was obtained. RESULTS: There were 490 patients enrolled in H@H versus 309 in preintervention group. The groups were similar in parity, race, ethnicity, and insurance status. There was no difference in the primary outcome, postpartum visit attendance (76.9% versus 76.1%, P=.77). H@H patients had a shorter postpartum length of stay (33.3 versus 46.7 hours, P&lt;.001), higher rates of exclusive breastfeeding at 1 week (59.2% versus 57.0%, P=.02), and a higher rate of contraceptive use (55% versus 44%, P=.01), with no difference in maternal unscheduled visits or hospital readmissions. CONCLUSION: This innovative postpartum program was associated with a shorter length of stay and improvement in contraceptive acceptance and breastfeeding without increasing unscheduled visits. Future studies should evaluate the cost-effectiveness of this program and expansion to higher-risk patients including those with cesarean delivery and medical comorbidities.

Accelerated discharge after aseptic revision knee arthroplasty is not associated with early readmission and reoperation.

In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations. Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation. Of 21,610 aseptic revision TKAs evaluated, 530 were discharged within 24 hours. Short-stay patients were younger (63.1 years (49 to 78) vs 65.1 years (18 to 94)), with lower BMI (32.3 kg/m2 (17 to 47) vs 33.6 kg/m2 (19 to 54) and lower ASA grades. Diabetes, chronic obstructive pulmonary disease, hypertension, and cancer were all associated with a hospital stay over 24 hours. Single component revisions (56.8% (n = 301) vs 32.4% (n = 6,823)), and shorter mean operating time (89.7 minutes (25 to 275) vs 130.2 minutes (30 to 517)) were associated with accelerated discharge. Accelerated discharge was not associated with 30-day readmission and reoperation. Accelerated discharge after revision TKA did not increase short-term complications, readmissions, or reoperations. Further efforts to decrease hospital stays in this setting should be evaluated.Cite this article: Bone Joint J2022;104-B(12):1323-1328.

Abstract 14227: Development of a Tool To Improve Risk Stratification of Patients With Atrial Fibrillation in the Emergency Department

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.

Ambulatory Lumbar Fusion: A Systematic Review of Perioperative Protocols, Patient Selection Criteria, and Outcomes.

Systematic review. The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion. As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices. This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes. The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs. There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis. Level III.

251 Emergency Department Arrival by Ambulance for Patients Receiving a Pulmonary Embolism Diagnosis Is Associated With Hospitalization: Is Coming from Off-site Radiology an Exception?

251 Emergency Department Arrival by Ambulance for Patients Receiving a Pulmonary Embolism Diagnosis Is Associated With Hospitalization: Is Coming from Off-site Radiology an Exception?

Accelerated Discharge After Aseptic Revision Total Hip Arthroplasty Does Not Predict Inferior 30-Day Outcomes

BackgroundPerioperative advancements have made outpatient primary total hip arthroplasty (THA) a viable option for patients. This study evaluated the feasibility of expedited discharge after revision THA and compared 30-day outcomes to patients who had prolonged inpatient hospitalizations. The authors hypothesized that expedited discharge would not result in inferior 30-day outcomes. MethodsAseptic revision THAs in a national database were reviewed from 2013 to 2020. THAs were stratified by hospital length of stay (LOS) more or less than 24 hours. Demographics, comorbidities, preoperative laboratory values, American Society of Anesthesiology (ASA) scores, operative times, components revised, 30-day readmissions, and reoperations were compared. Multivariable analyses evaluated predictors of discharge prior to 24 hours, 30-day readmissions, and reoperations. Of 17,044 aseptic revision THAs, 211 were discharged within 24 hours. ResultsAccelerated discharge patients were younger, mean age 63 years (range, 20-92) versus 66 years (range, 18-94) (P < .01) had lower body mass index, mean 28.7 (range, 18.3-46.4) versus 29.9 (range, 17.3-52.5) (P = .01), and ASA scores (ASA, 1-2; 40.4-57.8%) (P < .01). Components revised had no association with LOS (P = .39); however, operative times were shorter and mean 100 minutes (range, 35-369) versus 139 minutes (range, 24-962) (P < .01) in accelerated discharge patients. Accelerated discharge patients had lower readmission rates (P < .01) but no difference in reoperation rates (P = .06). ConclusionDischarge less than 24 hours after revision THA is a feasible option for the correct patient and further efforts to decrease LOS should be evaluated.

The analgesic benefit of Pericapsular Nerve Group (PENG) block in hip arthroscopic surgery: a retrospective pragmatic analysis at an academic health center

IntroductionThe novel pericapsular nerve group (PENG) block has recently been reported to provide effective motor-sparing local anesthetic-based analgesia to the hip joint. We aimed to evaluate the analgesic efficacy and...

Outcomes of Expedited Discharge After Isolated Coronary Artery Bypass Grafting

Expedited discharge after coronary artery bypass grafting (CABG) has been postulated as a possible solution for reducing hospitalization costs. This study aimed to evaluate the impact of expedited postoperative discharge on readmissions and costs in patients undergoing isolated CABG. Adults (≥18 years) who underwent isolated CABG were identified using the 2016-to-2019 Nationwide Readmission Database. Patients were classified as expedited or routine, with expedited patients being discharged on or before postoperative day 4. Those who experienced perioperative complications were excluded. The Nationwide Readmissions Database. Patients ≥18 years old who underwent isolated CABG. Of an estimated 187,591 patients meeting study criteria, 37.2% (n=69,861) experienced expedited discharge. Expedited patients experienced lower index hospitalization costs ($28,543 v $34,114, p < 0.001), and were less likely to experience 30-day nonelective readmission (4.6% v 7.3%, p < 0.001) and 90-day nonelective readmission (5.6% v 8.7%, p < 0.001). After adjustment, expedited discharge remained independently associated with reduced odds of both 30-day (adjusted odds ratio [AOR]: 0.78, 95% CI: 0.71-0.85) and 90-day (AOR: 0.80, 95% CI: 0.74-0.87) nonelective readmission. In addition, expedited discharge was associated with an incremental decrease in index hospitalization costs (β: -5,661, 95% CI: -5,894 to -5,429). Expedited discharge immensely decreases costs of care for patients undergoing isolated CABG, as well as readmission risks. Expedited discharge may be considered a strategy to both improve postoperative patient care and reduce hospitalization costs within the United States healthcare system.

Expedited postpartum discharge during the COVID-19 pandemic and acute postpartum care utilization

Background Early postpartum discharges increased organically during the COVID-19 pandemic. It is not known if this ‘natural experiment’ of shorter postpartum hospital stays resulted in increased risk for postpartum readmissions and other acute postpartum care utilization such as emergency room encounters. Objective The objectives of this study were to determine which clinical factors were associated with expedited postpartum discharge and whether the expedited postpartum discharge was associated with increased risk for acute postpartum care utilization. Methods This retrospective cohort study evaluated birth hospitalizations at affiliated hospitals during two periods: (i) the apex of the ‘first wave’ of the COVID-19 pandemic in New York City (3/22/20 to 4/30/20) and (ii) a historical control period of one year earlier (3/22/19 to 4/30/19). Routine postpartum discharge was defined as ≥2 d after vaginal birth and ≥3 d after cesarean birth. Expedited discharge was defined as <2 d after vaginal birth and <3 d after cesarean birth. Acute postpartum care utilization was defined as any emergency room visit, obstetric triage visit, or postpartum readmission ≤6 weeks after birth hospitalization discharge. Demographic and clinical variables were compared based on routine versus expedited postpartum discharge. Unadjusted and adjusted logistic regression models were performed to analyze factors associated with (i) expedited discharge and (ii) acute postpartum care utilization. Unadjusted (ORs) and adjusted odds ratios (aORs) with 95% CIs were used as measures of association. Stratified analysis was performed restricted to patients with chronic hypertension, preeclampsia, and gestational hypertension. Results A total of 1,358 birth hospitalizations were included in the analysis, 715 (52.7%) from 2019 and 643 (47.3%) from 2020. Expedited discharge was more common in 2020 than in 2019 (60.3% versus 5.0% of deliveries, p < .01). For 2020, clinical factors significantly associated with a decreased likelihood of expedited discharge included hypertensive disorders of pregnancy (OR 0.40, 95% CI 0.27–0.60), chronic hypertension (OR 0.14, 95% CI 0.06–0.29), and COVID-19 infection (OR 0.51, 95% CI 0.34–0.77). Cesarean (OR 3.00, 95% CI 2.14–4.19) and term birth (OR 3.34, 95% CI 2.03, 5.49) were associated with an increased likelihood of expedited discharge. Most of the associations retained significance in adjusted models. Expedited compared to routine discharge was not associated with significantly different odds of acute postpartum care utilization for 2020 deliveries (5.4% versus 5.9%; OR 0.92, 95% CI 0.47–1.82). Medicaid insurance (OR 2.30, 95% CI 1.06–4.98) and HDP (OR 5.16, 95% CI: 2.60–10.26) were associated with a higher risk of acute postpartum care utilization and retained significance in adjusted analyses. In the stratified analysis restricted to women with hypertensive diagnoses, expedited discharge was associated with significantly increased risk for postpartum readmission (OR 6.09, 95% CI 2.14, 17.33) but not overall acute postpartum care utilization (OR 2.17, 95% CI 1.00, 4.74). Conclusion Expedited postpartum discharge was not associated with increased risk for acute postpartum care utilization. Among women with hypertensive diagnoses, expedited discharge was associated with a higher risk for readmission despite expedited discharge occurring less frequently.