Likelihood Of Same-day Discharge Research Articles

HPB P31 Delayed discharges in day-case cholecystectomies, a real issue?

Abstract Background Elective cholecystectomies are a very common general surgical procedure accounting for approximately 66660 cases a year and costing large amounts of resources to the NHS with significant regional variations in day-case rates1. Initiatives such as Get it Right First Time (GIRFT) aimed at improving the treatment of NHS patients are currently pushing for an increase in day-case rate to at least 75% of all cases and a decrease in regional variations2. The aim of this project was to determine how many patients underwent a day-case elective cholecystectomy, the percentage of delayed discharges and any reasons for the delay. Methods Retrospective analysis for which all adult patients admitted for a cholecystectomy at a district general hospital, in six consecutive months were included. For all included patients, ASA score, average age, length of stay, diagnosis and reason for delayed discharge were recorded. Reported complications were also included in the analysis. All data was collected via screening of local electronic health records. Results 217 patients were included in the analysis. 58% were discharged on the same day; of those not discharged on the same day non-elective operations and planned elective inpatients accounted for 28% and 17% of the total respectively. 75% of all included patients was female and all planned day-cases patients were either ASA1 or 2. Reasons for delayed discharge of planned day-cases included drain placement (18%), social issues (4%), nausea and pain (10%), not meeting discharge criteria such as inability of passing urine (14%) and for 24% of patients no reason was recorded. Conclusions Studies have shown that the combination of high ASA and increasing age reduce the likelihood of same day discharge.3 Our study found documentation to be often inaccurate and a potential for better pre-operative selection of patients in order to ensure high levels of safe day-case cholecystectomies.

COVID-19 as a Catalyst for Same Day Discharge After Minimally Invasive Hysterectomy

Objective: This study quantified the COVID-19 pandemic's impact on same-day discharges for minimally invasive hysterectomy and evaluated the effect on postoperative morbidity and health care use. Materials and Methods: This retrospective cohort study, from March 2018 to October 2021 at a single institution, included women older than age 18 who had laparoscopic, vaginal, or robotic-assisted hysterectomy by any gynecologic surgeon. Primary outcome was rate of same-day hospital discharge. Secondary measures were length of stay and rates of 30-day postoperative morbidity and health care use. Univariate and multivariable logistic regression analyses were conducted to evaluate associations between patients' characteristics and likelihood of same-day discharge. Results: There were 1608 women included, 896 in a prepandemic cohort and 712 in a postpandemic cohort. Surgeon subspecialty rates were similar between groups, but surgical approaches differed, with more laparoscopic procedures in the postpandemic cohort (p = 0.007). Case order and lengths, and concurrent procedures were not different between groups. Postpandemic patients were more likely to be discharged on the same day even after controlling for confounders in a multivariable regression (32% versus 54%, respectively; odds ratio: 2.78; p < 0.001). Rates of 30-day postoperative complications, transfusions, emergency department visits, readmissions, reoperations, and mortality were not significantly different. Conclusions: The COVID-19 pandemic was associated with increased same-day discharges without increases in 30-day postoperative complications. The data confirmed that same-day discharge following minimally invasive hysterectomy was safe for managing hospital constraints caused by the COVID-19 pandemic. (J GYNECOL SURG 20XX:000)

Does prostate artery embolization prior to Aquablation® reduce peri-operative morbidity and increase the likelihood of same day discharge?

Does prostate artery embolization prior to Aquablation® reduce peri-operative morbidity and increase the likelihood of same day discharge?

Safety and feasibility of same-day discharge following minimally invasive hysterectomy in the morbidly obese patient population

ObjectivesTo determine whether morbid obesity should serve as an independent factor in the decision for same day discharge following minimally invasive hysterectomy. MethodsRetrospective review was performed of patients with BMI ≥ 40 who underwent minimally invasive hysterectomy within a single comprehensive cancer center between January 2018 – August 2020. Demographics, perioperative factors, post-operative monitoring, complications, and readmissions were compared between patients who underwent same day discharge and overnight observation using Fisher's exact tests and Wilcoxon rank-sum tests. Results374 patients with BMI ≥ 40 were included. Eighty-three (22.2%) patients underwent same day discharge, and 291 (77.8%) patients underwent overnight observation. Factors associated with increased likelihood of same day discharge included younger age (median age 53 vs 58; p = 0.001), lower BMI (median BMI 45 vs 47; p = 0.005), and fewer medical co-morbidities (Charlson Co-Morbidity Index 2 vs 3; p < 0.001). On multivariate regression analysis, frailty (OR 2.16 [1.14–4.11], p = 0.019) and surgical completion time after 12 PM (OR 3.67 [2.16–6.24], p < 0.001) were associated with increased risk of overnight observation. Few patients admitted for routine overnight observation required medical intervention (n = 14, 4.8%); most of these patients were frail (64.3%). The overall hospital readmission rate within 30 days of discharge was 3.2% (n = 12), with no patients discharged on the day of surgery being readmitted. ConclusionsMorbid obesity alone should not serve as a contraindication to same day discharge following minimally invasive hysterectomy. Admission for observation was associated with low rates of clinically meaningful intervention, and patients who underwent same day discharge were not at increased risk of adverse outcome.

Same-day Discharge after Robotic Hysterectomy for Benign Conditions: Feasibility and Safety

To investigate the feasibility and predictive factors for same-day discharge (SDD) after robotic hysterectomy (RH) for benign indications to optimize patient selection by incorporating preoperative, intraoperative, and postoperative variables. A single-center retrospective cohort study. Tertiary academic hospital. Patients undergoing RH for benign indications. Patients were designated for SDD by implementing enhanced recovery after surgery protocol. The study included 890 patients who underwent RH for benign indications between the years 2016 and 2021. Of these, 618 (69.4%) were discharged the same day and 272 (30.5%) were admitted for overnight stay. Both groups had similar age (46.4 vs 46.2 years), body mass index (28.3 vs 28.9), and indications for surgery. In multivariable logistic regression, factors that were significant for overnight stay were American Society of Anesthesiologists score 3, Charlson comorbidity index, previous laparotomy, and operative time. Other factors such as surgery start time and preoperative hemoglobin levels were not statistically significant. Postoperative outcomes were comparable for both groups with similar readmission and reoperation rates. The likelihood of SDD after RH in this cohort after implementing enhanced recovery after surgery protocol was almost 70%, and most of the predictive factors for overnight stay were nonmodifiable. Importantly, both groups had similar outcomes after surgery.

Postoperative outcomes of mepivacaine vs. bupivacaine in patients undergoing total joint arthroplasty with spinal anesthesia

BackgroundSpinal anesthesia (SA) has been previously associated with improved outcomes after total joint arthroplasty (TJA). The purpose of this study was to compare outcomes between various local anesthetics.MethodsThis was a retrospective study of 1,328 patients undergoing primary TJA with SA from September 2020–2021 at a single institution. Patients were grouped based on TKA or THA and further separated and analyzed in terms of anesthetic agents—mepivacaine (M), hyperbaric bupivacaine (HB), or isobaric bupivacaine (IB). Subgroup analysis of same-day-discharge (SDD) patients and low- (<11 mg) and high-dose bupivacaine was performed. Statistical significance was assessed at P<0.05.ResultsMepivacaine use was associated with younger age, lower ASAs, and lower Charlson Comorbidity Index (CCI) scores in both THAs and TKAs. Postoperatively, significant differences were found between HB, IB, and M in LOS, the first PT ambulation distance and rates of SDD, and home discharge in both THAs and TKAs. No significant differences in outcomes were observed between high- and low-dose bupivacaine in THAs or TKAs. In SDD patients, a significant difference was found only in the first 6-clicks mobility scores. After controlling for age, BMI, sex, ASA, and procedure type, mepivacaine was found to be associated with shorter LOS, increased likelihood of SDD, home discharge, POD-0 ambulation, and, further, the first ambulation distance. No significant differences were observed in 6-clicks mobility scores, urinary retention, 30-day ED returns or 30-day readmissions.ConclusionsBoth bupivacaine and mepivacaine are safe and effective local anesthetics for patients undergoing TJA as evidenced by low, similar rates of urinary retention and 30-day ED returns and readmissions. Mepivacaine does appeared to facilitate early ambulation, shorter LOS and home discharge and should be considered as the local anesthetic of choice for patients undergoing rapid recovery TJA.

Factors Associated with Prolonged Ambulatory Surgery Stay for Major Gynecologic Surgery

Study Objective To identify factors associated with overnight admission after major minimally invasive gynecologic surgery, and create a prediction model. Design Retrospective cohort study. Setting Academic Medical Center. Patients or Participants Patients undergoing major minimally invasive surgery by a single surgeon between 2018 and 2020. Interventions Pre-operative patient characteristic data and peri-operative data were collected retrospectively. Logistic regression analysis of factors associated with same-day discharge versus overnight admission was performed. Measurements and Main Results 461 major minimally invasive cases were identified, of which 425 cases were considered eligible for ambulatory surgery discharge and were included in the analysis. 279 (65.6%) patients were discharged same-day, and 146 (34.4%) were admitted.Patients with later procedure start times (OR 0.9), cancer pathology (OR 0.4), high four-hour postoperative pain scores (OR 0.8), and presence of urinary catheter in the recovery room (OR 0.1) had significantly decreased likelihood of same-day discharge. A prediction model including nineteen patient characteristic and peri-operative variables explained 57.8% of the variability of whether or not patients were admitted after surgery. The model correctly predicted 69.3% of admissions and 90.1% of same-day discharges, giving an overall prediction rate of 82.4%. 7 (2.5%) patients discharged same-day and 4 (2.7%) patients admitted returned to the emergency room within 30 days; 1 (0.4%) patient discharged same-day and 4 (2.7%) patients admitted had a readmission within 30 days. Conclusion Peri-operative factors such as surgery start time, postoperative pain level, presence of urinary catheter in the recovery room as well as diagnosis of malignancy are predictive of overnight admission. Postoperative hospital stay does not improve 30-day readmission rates or the number of ER visits after the discharge. Knowledge of factors associated with prolonged stay after major ambulatory surgery can aid in counseling and peri-operative planning.

Complex high-risk and indicated percutaneous coronary intervention for stable angina: Does operator volume influence patient outcome?

Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes. Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001). CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival. Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.

Association of Same-Day Discharge After Elective Percutaneous Coronary Intervention in the United States With Costs and Outcomes

Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. This observational cross-sectional cohort study included 672 470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. Among 672 470 elective PCIs, 221 997 patients (33.0%) were women, 30 711 (4.6%) were Hispanic, 51 961 (7.7%) were African American, and 491 823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.

Misoprostol priming prior to second trimester medical abortion

Misoprostol priming prior to second trimester medical abortion