Fast-track Discharge Research Articles

393 Towards Sustainable Care Pathways: A Review of Outpatient Appointments for Elderly Patients Under Fast-Track Discharge from Surgical Specialties

393 Towards Sustainable Care Pathways: A Review of Outpatient Appointments for Elderly Patients Under Fast-Track Discharge from Surgical Specialties

Case report on confusion: an unusual presentation of lung cancer

Introduction: Cancer of the lung can be insidious and manifest clinicallyin relatively unexpected forms. The incidence of hyponatremia in lungcancer is 18.9% [1].Case: An 87-year-old woman presented with confusion. She smoked10–15 cigarettes a day for 70 years. Blood tests done; Na: 118. I made animpression of severe symptomatic hyponatremia secondary to suspectedSiADH from possible small cell lung cancer.I requested CXR, urine Na, paired osmolality, fluid restricted and discussedwith the medical registrar who suggested a transfer to Generalhospital. CXR showed a round mass in the right upper lobe.At the GH, Na was replaced slowly and the patient was planned forCT scans. After 2 days, she developed gradual SOB (? PE). CT scans weredelayed because she could not lie flat and got SOB. ENT and anaesthesiareviewed her and suggested supported airway CT under GADay 5 – Distended neck veins? SVCO. Anaesthetists were no longercomfortable with GA. Unfortunately, steroids did not make her morecomfortable. DNAR in place, family informed of poor prognosis andrequested fast track discharge with palliative support. Died at home after18 days.Conclusion: While it is quite unusual for a respiratory condition to presentwith confusion, quick recognition, open mindedness, and inter disciplinarycooperation are essential in day-to-day practice.

Fast-track discharge following percutaneous endoscopic gastrostomy removal in head and neck cancer patients after remission: a feasibility and safety study

Introduction and AimHead and neck cancer patients (HNCP) often require enteral nutritional support during chemoradiotherapy (CRT) possibly using a percutaneous endoscopic gastrostomy (PEG). Patients achieving complete oncological response and successfully resuming normal oral intake, will be scheduled for the removal of PEG post-treatment. We aim to evaluate the feasibility and safety of PEG tube removal with immediate discharge. MethodsProspective, observational, unicentric study, including all HNCP scheduled for PEG removal from October 2020 to February 2022. HNCP in remission had PEG removal with discharge after 30minutes and re-beginning cold liquid diet after 3hours. Additional therapy with omeprazole 40mg bid orally for 4 weeks was prescribed. Patients were scheduled for re-evaluation appointment after 1 month. ResultsDuring the study period, 120 HNCP scheduled for PEG removal were enrolled, with an adverse events rate of 6,7%, including seven (5.8%) persistent gastrocutaneous fistulas (GCF) and one (0.8%) parastomal hernia. 6/7 GCF solved with medical therapy alone (additional 4 weeks of PPI),1/7 required endoscopic therapy and the parastomal hernia was referred for surgery. There was no association between adverse events and patient age (p 0,343), tumor location (p=0,305) or stage (p=0,605), diabetes mellitus diagnosis (p=0,813), smoking habits (p=0,274), PEG duration (p=0,645), caliber (p=0,587) or previous PEG infections (p=0,659). ConclusionPEG removal with immediate discharge is safe, has low rate of adverse events that mostly resolve with medical therapy.

Postoperative Day 1 Discharge After Robotic Totally Endoscopic Coronary Bypass: The Ultimate in Enhanced Recovery After Surgery.

The benefits of Enhanced Recovery After Surgery (ERAS) protocols are being recognized in multiple surgical specialties, including following coronary bypass surgery to improve quality of care and decrease costs. We developed a fast-track discharge protocol for patients undergoing robotic totally endoscopic coronary bypass surgery (TECAB) to be discharged on postoperative day (POD) 1, the subjects of this study. In a retrospective study of 720 patients undergoing robotic beating-heart TECAB over 8 years at our institution, 93 patients were selected for a fast-track POD1 discharge protocol. We compared the outcomes of this group to the remaining 627 patients who were discharged per standard protocol (non-POD1 discharge). The early discharge group was significantly younger, had lower Society of Thoracic Surgeons (STS) risk of mortality, and had a lower prevalence of obesity, diabetes, and chronic kidney disease. Patients discharged on POD1 were more often extubated in the operating room (56% vs 42%, P = 0.010). The readmission rate for the early discharge group was 3.2%, which was similar to the readmission rate of 6.7% for the standard discharge protocol group (P = 0.329). Time to return to work was shorter in the early discharge group, although it did not quite reach statistical significance (12 vs 18 days, P = 0.051). There was no difference in midterm cardiac mortality. Early discharge on POD1 after robotic TECAB is appropriate in selected patients and is associated with low readmission rates and a trend towards earlier return to work. Patients suitable for this "ultrafast-track" approach were more likely to be younger, have lower STS risk, and fewer comorbidities.

Fast-Track Nonelective Laparoscopic Cholecystectomy is Safe and Feasible

IntroductionAmple evidence exists to support the safety of fast-track discharge after elective laparoscopic cholecystectomy (LC), but there is currently no data available to support the safety of fast-tracking patients undergoing nonelective LC. We sought to determine whether fast-tracking patients undergoing nonelective LC is safe and feasible. MethodsWe performed a retrospective cohort review of 661 consecutive patients undergoing LC at a single teaching institution from April 2018 to January 2020. Subjects were divided into two groups: elective LC (ELC) and fast-track nonelective LC (FTLC). FTLC was defined as nonelective LC with total length of stay <36 h. Patients undergoing nonelective LC with length of stay exceeding 36 h were excluded. The primary outcome of interest was readmission within 30 d. The secondary outcomes included incidences of return to emergency department within 30 d, retained stone, bile leak, and wound infection. ResultsOf 661 LC, 185 (27%) were ELC and 476 (72%) were nonelective. FTLC included 121 (25%) of the nonelective LC. Preoperative characteristics were similar among the groups. On final pathology, chronic cholecystitis was predominant in both groups, but FTLC exhibited higher rates of acute cholecystitis (P < 0.0001). There was no significant difference in the primary outcome among groups: readmission within 30 d occurred in 6 (3%) ELC patients and 4 (3%) FTLC patients (P = 1.0). There were no significant differences in rates of return to emergency department within 30 d, retained stone, bile leak, or wound infection. ConclusionsWith comparable postoperative complication rates to ELC, FTLC can be safely used in select patients. Additional studies are needed to determine preoperative predictors of FTLC suitability to prospectively identify appropriate patients.

Predictors of early discharge after transcatheter aortic valve implantation: insight from the CoreValve ClinicalService.

The aim of this study was to minimize the procedure, and reduce the length of hospital stay (LoS) is the future objective for transcatheter aortic valve replacement (TAVI).Aims of the study are to identify procedural and electrocardiographical predictors of fast-track discharge in patients who underwent TAVI. Patients treated with TAVI included in the One Hospital ClinicalService project were categorized according to the LoS. 'Fast-Track' population, with a postprocedural LoS less than or equal to 3 days, was compared with the 'Slow-Track' population with a postprocedural LoS greater than 3 days. One thousand five hundred and one patients were collected. Despite single baseline characteristics being almost similar between the two groups, Slow-Track group showed a higher surgical risk (P < 0.001). Patients in the Slow-Track group were more frequently treated with general anaesthesia (P = 0.002) and less frequently predilated (P < 0.001) and received a lower amount of contrast media. No difference between Slow-Track and Fast-Track patients was observed at 30 days in death and in cardiovascular rehospitalization.In the multivariable analysis, STS score of at least 4% [odds ratio (OR): 1.64; P = 0.01], general anaesthesia (OR: 2.80; P = 0.03), predilation (OR: 0.45; P < 001), NYHA 3-4 at baseline (OR: 1.65; P = 0.01), AVB I/LBBB/RBBB onset (OR: 2.41; P < 0.001) and in-hospital new PM (OR: 2.63; P < 0.001) were independently associated with a higher probability of Slow-Track. Fast-Track patients were safely discharged home showing no difference in clinical outcomes after discharge up to 30 days compared with the Slow-Track group. The STS score, general anaesthesia, NYHA 3--4 at baseline, in-hospital onset of conduction disturbances and new PM implantation after TAVI turned out to be predictors of Slow-Track.

Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques.

As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019-2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.

Length of hospital stay in aneurysmal subarachnoid hemorrhage patients without vasospasm on angiography: potential for a fast-track discharge cohort

BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) frequently suffer from vasospasm. We analyzed the association between absence of early angiographic vasospasm and early discharge.MethodsAll aSAH patients treated from August 1, 2007,...

Transcatheter procedures in structural heart disease: The surgeon stepping-in.

The seismic impact of transcatheter interventions is rocking the spectrum of structural heart disease (SHD) treatment, with the compelling and attractive appeal of minimally invasive procedures and fast-track discharge. The trend is relentless and continual innovation comes to our doors nearly on a daily basis. Litwinowicz and colleagues describe their trailblazing experience in 223 consecutive patients in whom they performed left atrial appendage occlusion via the percutaneous route. All interventions were performed by surgeons, who had undergone pretraining in a simulation model. Soon thereafter, they were able to achieve outcomes that were comparable with those obtained by experienced interventional cardiologists. The unique surgeons' training and skills in open-heart surgery make their contribution to perfection and safety of SHD treatment, which are potentially exceptional and distinctive. Extrapolating for the entire field of SHD, which is blossoming ahead, the message to be conveyed is that cardiac surgeons must be trained and embrace every aspect of SHD.

Subarachnoid Hemorrhage "Fast Track": A Health Economics and Health Care Redesign Approach for Early Selected Hospital Discharge.

ObjectiveTo determine whether earlier hospital discharge is feasible and safe in selected patients with subarachnoid hemorrhage (SAH) using an outpatient “fast-track” protocol.Patients and MethodsWe conducted a prospective quality improvement cohort study with the primary feasibility end point of patients with SAH deemed safe for discharge by treating team consensus. All patients received detailed education and outpatient transcranial Doppler monitoring; caregivers could contact the on-call team 24-7. Primary safety end points were adverse events after discharge and hospital readmission.ResultsFrom January 1, 2010, to January 1, 2015, our center had 377 SAH diagnoses, of which 200 were included in the final cohort, 36 qualifying for fast-track early discharge. The 30-day readmission rate for fast-track patients was 11.0% (4 of 36) compared with 11.4% (18 of 164) for non–fast-track patients. The rate of delayed cerebral ischemia and stroke was 3% (1 of 36) in the fast-track group vs 25.0% (41 of 164) for the non–fast-track group. Adverse events occurred in 11.0% (4 of 36) of the fast-track group compared with 26.0% (43 of 164) in the non–fast-track group. The mean length of stay was reduced 60% from 15 days to 6.6 days in the fast-track group.ConclusionAlthough our fast-track group was relatively small, data suggested early feasibility and safety in a carefully selected group of patients with SAH. Direct and indirect financial benefits of early discharge over a 5-year period were an estimated savings at least $864,000 in overall costs. A comparative effectiveness study is planned to replicate and validate these results using a larger multicenter design.

Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery

ObjectiveDischarge policies concerning hospitalization after endoscopic pituitary tumor surgery are highly variable. A few studies support fast-track discharge; however, this is not commonplace. Our goal was to report the transition to and evaluate the feasibility, safety, clinical- and patient-reported outcomes and costs of fast-track care in pituitary surgery.MethodsThis observational study included 155 patients undergoing pituitary surgery between December 2016 and December 2018. Fast-track care consisted of planned discharge 2–3 days after surgery, followed by daily surveillance by a case manager. All outcomes were compared with patients not eligible for fast-track discharge. The total group (fast-track and non-fast-track) was compared with historic controls (N = 307).ResultsA total of 79/155 patients (51%) were considered eligible for fast-track discharge, of whom 69 (87%) were discharged within 3 days. The total group was discharged more often within 3 days compared with historic controls (49 vs. 20%, p < 0.001), the total length of stay did not differ (5.3 vs. 5.7 days, p = 0.363). Although the total group had more readmissions compared with historic controls (17 vs. 10%, p = 0.002), no life-threatening complications occurred after discharge. On average, clinical- and patient-reported outcomes improved over time, both in the fast-track and non-fast-track groups. The mean overall costs within 30 days after surgery did not differ between the total group € 9992 (SD € 4562) and historic controls € 9818 (SD € 3488) (p = 0.649).ConclusionA stratified fast-track care trajectory with enhanced postoperative outpatient surveillance after pituitary tumor surgery is safe and feasible. As expected, costs of the fast-track were lower than the non-fast-track group, however we could not prove overall cost-effectiveness compared with the historic controls.

Fast-Track Eligibility and Hospital Discharge for Outpatient Lumbar Discectomy

Fast-Track Eligibility and Hospital Discharge for Outpatient Lumbar Discectomy

Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study

Background and objectivesAlthough high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact...

Efficacy of adductor canal block protocol implementation in a multimodal pain management protocol for total knee arthroplasty

ObjectivePostoperative pain relief for total knee arthroplasty is an important concern for clinicians who seek to decrease pain, side effects associated with narcotics, increase mobility, and decrease hospital length of stay for total knee arthroplasty (TKA) patients. In today's day in age where patients and clinicians are looking to decrease length of stay and desire to take total knee replacement to the ambulatory surgery setting, appropriate and safe analgesia is paramount. The purpose of this study was to evaluate the analgesic efficacy of implementing a single shot adductor canal block (ACB) protocol in patients undergoing primary TKA by a single surgeon already using a multimodal analgesia protocol at a high volume community hospital. Methods75 patients who received a single shot ACB were compared to 75 patients that did not receive an ACB with respect to post-operative NRS pain scores and narcotic consumption. ResultsAfter addition of an ACB there was a 90% reduction in NRS pain scores in the PACU and a 38% reduction at 12 and 24-h post-operatively which were all statistically significant. Total post-operative morphine milligram equivalent (MME) decreased by 51%, after addition of an ACB, which was also statistically significant. ConclusionThe administration of an ACB as an adjunct to a multimodal pain protocol for primary TKA patients is effective at minimizing post-operative pain and narcotic consumption, and plays a critical role in facilitating fast track and same day discharge in our practice.

Identifying and preventing delays in the fast-track discharge process

Background: The fast-track discharge planning service in hospital is available to patients with a rapidly deteriorating condition who may be entering a terminal phase, and aims to ensure individuals are supported in their preferred place of care quickly. This project aimed to identify where delays in this process are occurring, and use this information to improve the service.

Identifying and preventing delays in the fast-track discharge process

Background: The fast-track discharge planning service in hospital is available to patients with a rapidly deteriorating condition who may be entering a terminal phase, and aims to ensure individuals are supported in their preferred place of care quickly. This project aimed to identify where delays in this process are occurring, and use this information to improve the service.

Reverse Vesicouterine Fold Dissection for Laparoscopic Hysterectomy After Prior Cesarean Deliveries.

Cesarean delivery adhesions, during laparoscopic hysterectomy, can present surgical challenges, including distortion of anatomy, prolonged operating time, and inadvertent injury to nearby structures. At the time of laparoscopic hysterectomy, in patients with significant adhesions from prior cesarean deliveries, we use a reverse inferior to superior vesicouterine fold dissection to mobilize the scarred bladder. We use this as an alternative to the commonly practiced technique of mobilizing the bladder in a superior to inferior fashion at the time of laparoscopic hysterectomy. Fifty-two patients with a median age of 42.5 years are presented. Forty-eight patients were discharged within 3-6 hours postoperatively. Sixteen patients were discharged with Foley catheters, because they were unable to void within the protocol for a fast-track discharge. The catheters were removed between postoperative days 1 and 5. There were no gastrointestinal or genitourinary complications. One patient experienced a delayed vaginal cuff abscess and bleeding, which were managed conservatively. Reverse vesicouterine fold dissection is a useful alternative technique for laparoscopic hysterectomy in women with a history of prior cesarean deliveries.

Experience with "Fast track" postoperative care after deep brain stimulation surgery.

A 24-h-stay in the post-anesthesia care unit (PACU) is a common postoperative procedure after deep brain stimulation surgery (DBS). We evaluated the impact of a fast-track (FT) postoperative care protocol. An analysis was performed on all patients who underwent DBS in 2 periods: 2006, overnight monitored care (OMC group), and 2007-2013, FT care (FT group). The study included 19 patients in OMC and 95 patients in FT. Intraoperative complications occurred in 26.3% patients in OMC vs. 35.8% in FT. Post-operatively, one patient in OMC developed hemiparesis, and agitation in 2 patients. In FT, two patients with intraoperative hemiparesis were transferred to the ICU. While on the ward, 3 patients from the FT developed hemiparesis, two of them 48h after the procedure. Thirty eight percent of FT had an MRI scan, while the remaining 62% and all patients of OMC had a CT-scan performed on their transfer to the ward. One patient in OMC had a subthalamic hematoma. Two patients in FT had a pallidal hematoma, and 3 a bleeding along the electrode. A FT discharge protocol is a safe postoperative care after DBS. There are a small percentage of complications after DBS, which mainly occur within the first 6h.

Psychiatric Disorders and Psychopharmacologic Treatment as Risk Factors in Elective Fast-track Total Hip and Knee Arthroplasty.

Psychiatric disorder (PsD) is rarely considered when evaluating perioperative risk factors. Studies on PsD are often limited by use of administrative coding, incomplete follow-up, and lack of preoperative data on psychopharmacological treatment. A multicenter study with prospective registration on preoperative comorbidity, complete 90-day follow-up, and information on dispensed prescriptions on psychopharmacological treatment (excluding benzodiazepines). All departments used similar fast-track approaches and discharge to home. Evaluation of postoperative morbidity was based on discharge records. Odds ratios for length of stay (LOS) more than 4 days and surgery-related readmissions were calculated using multiple logistic regression adjusting for potential confounders. Of 8,757 procedures, 1,001 (11.4%) were in PsD patients. Of these, 43.4% used selective serotonin inhibitors (SSRIs), 31.6% used other antidepressants, 8.5% used a combination, and 16.5% used antipsychotics. PsD was associated with increased risk of LOS more than 4 days (16.5 vs. 7.3%; odds ratio, 1.90; 95% CI, 1.52 to 2.37), regardless of treatment with SSRIs (2.19; 1.62 to 2.97), other antidepressants (1.81; 1.25 to 2.61), or antipsychotics (1.90; 1.62 to 3.16). PsD was associated with increased 30- (9.9 vs. 5.1%; 1.93; 1.49 to 2.49) and 90-day surgery-related readmissions (12.8 vs. 7.4%; 1.68; 1.34 to 2.10), significant for SSRIs (1.97; 1.38 to 2.82 and 1.77; 1.29 to 2.43), other antidepressants (2.24; 1.51 to 3.32 and 1.82; 1.27 to 2.61), and antipsychotics (1.85; 1.03 to 3.31, 30 days only). In PsD patients, pain (1.4%), postoperative anemia (1.1%), and pulmonary complications (1.1%) were the most frequent causes of LOS more than 4 days. Hip displacements (2.8%) and falls (1.9%) were the most frequent readmissions, and 90-day surgery-related mortality was 0.7% with and 0.2% without PsD. Psychopharmacologically treated PsD is a risk factor for postoperative morbidity after fast-track arthroplasty, regardless of treatment type. This may be due to PsD per se and/or drug-related side effects.

Improving confidence and competence of healthcare professionals in end-of-life care: an evaluation of the ‘Transforming End of Life Care’ course at an acute hospital trust

BackgroundUK policymakers, clinicians and public wish to see improvements in end-of-life care (EoLC). However, healthcare professionals’ skills and knowledge to deliver high-quality care are often lacking. Since May 2012, palliative...