Mean Postoperative Length Of Stay Research Articles

A Risk Prediction Model for Prolonged Length of Stay After Minimally Invasive Valve Surgery.

Minimally invasive surgery determines shorter postoperative hospital length of stay (LOS) even in cardiac surgery. Potential preoperative factors affecting LOS are still not known in minimally invasive heart valve surgery (MIVS). We aimed to identify preoperative variables influencing prolonged LOS in MIVS. We reviewed 189 patients who underwent MIVS via minithoracotomy at our institution. Prolonged LOS was defined as more than 7 postoperative days. Poisson and logistic regression were used to screen the predictors. The mean postoperative LOS was 9.13 days, and 64 patients (33.9%) experienced a prolonged LOS. These patients were older, more frequently in New York Heart Association (NYHA) class III or IV, showed worse left ventricular ejection function (LVEF), and had a higher incidence of reoperation and chronic kidney disease (CKD). At univariate analysis, the most significant preoperative factors affecting prolonged LOS were age (odds ratio [OR] = 1.04), NYHA class III or IV (OR = 3.03), reduced LVEF (OR = 3.22), CKD (OR = 2.7), and redo surgery (OR = 3.6). After adjustment, the most significant preoperative factors predicting prolonged LOS were age (OR = 1.03, 95% CI: 1.01 to 1.06, P = 0.02) and redo surgery (OR = 3.33, 95% CI: 1.29 to 8.9, P = 0.01). The most important factors affecting prolonged LOS after MIVS were represented by age and redo surgery, although other preoperative characteristics such as reduced LVEF, NYHA class III or IV, and CKD play a significant role in delaying recovery after MIVS. Further larger studies are needed to better identify potential preoperative predictors of prolonged LOS after MIVS.

Factors Associated With Unplanned Readmissions and Prolonged Length of Stay in Patients Undergoing Primary Fusion for Congenital Scoliosis.

Approximately 50% of patients with congenital scoliosis will require surgical treatment to prevent further progression. Outcomes following congenital scoliosis are sparse in the literature. The purpose of this study was to identify independent risk factors associated with unplanned readmission and prolonged length of stay (LOS) in patients undergoing primary surgical treatment for congenital scoliosis. The National Surgical Quality Improvement Database-Pediatric was queried for database years 2016-2018 to identify patients with congenital scoliosis who underwent primary posterior fusion of the spine. Patient demographics, comorbidities, and operative variables, such as the number of levels fused and the American Society of Anesthesiologists (ASA) classificaiton, were collected. Univariate and multivariate analyses of patient factors were performed to test for association with readmission within 30 days and prolonged LOS (>4 days). Eight hundred sixteen patients were identified. The average age was 11.3 ± 4.02 years, and the mean postoperative LOS was 4.64 ± 3.71 days. Forty-three patients (5.40%) were readmitted, and 73 patients (8.96%) had prolonged LOS. Independent risk factors associated with prolonged LOS included chronic lung disease (P < 0.001), presence of a tracheostomy (P < 0.001), structural central nervous system abnormality (P = 0.039), oxygen support (P < 0.001), and number of levels fused (P = 0.008). The factors independently associated with unplanned readmission were fusion to the pelvis (P = 0.004) and LOS >4 days (P = 0.008). Prolonged LOS and readmission are widely being used as quality and performance metrics for hospitals. Congenital scoliosis, which often progresses rapidly resulting in significant deformity, frequently requires surgery at an earlier age than idiopathic and neuromuscular deformity. Nevertheless, 30-day outcomes for surgical intervention have not been thoroughly studied. The present study identifies risk factors for prolonged LOS and readmission, which can facilitate preoperative planning, patient/family counseling, and postoperative care. Congenital scoliosis management poses certain challenges that may be mitigated by understanding the risk factors for adverse outcomes following primary fusion surgery.

Machine Learning to Predict Length of Stay Following Revision Hip Arthroplasty

AbstractPredicting length of stay (LOS) for revision total hip arthroplasty (rTHA) remains challenging due to the complexity of cases and increased complication rates compared with primary total hip arthroplasty. Artificial intelligence may play a role in predicting LOS after rTHA. This study aims to develop a machine learning model to predict LOS in rTHA patients based on preoperative and intraoperative factors. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients undergoing a rTHA between 2012 and 2018. The data were used to train both random forest machine and logistic regression machine learning models to predict short LOS (≤ 1 day) or long LOS (≥ 2 days). Statistical analysis was performed to analyze differences between short and long LOS groups. Logistic regression analysis was used to calculate odds ratios associated with long LOS. A total of 4,228 patients were identified in this analysis with a mean postoperative LOS of 3.69 days. Preoperative features associated with a short LOS included male sex, noninfectious revision, spinal anesthesia, later year of operation, younger age, smoking history, and lower body mass index. Area under the receiver operating characteristic curve was calculated to measure model performance for the random forest model and logistic regression model as 0.76 and 0.78, respectively. The machine learning model presented here was able to reasonably predict LOS for revision hip arthroplasty showing promise for use as patient selection tool to identify short LOS patients.

An institutional experience in applying quality improvement measures to pituitary surgery: clinical and resource implications.

The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations. Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022). Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498. CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

Enhanced recovery management in pediatric pyeloplasty: outcomes in a single institution and tips for improvement.

We report the application of enhanced recovery after surgery (ERAS) regimens to pediatric patients undergoing laparoscopic pyeloplasty (LP), aiming to guide the practice of ERAS in pediatric LP. From October 2018, we prospectively implemented a twenty-point ERAS regimen, including a modified LP procedure, for pediatric UPJO patients in a single institution. Data from 2018 to 2021 were collected and analyzed retrospectively. The variables gathered included: demographics, preoperative details and recovery elements. Outcomes were postoperative length of stay (POS), readmission rate, operation time and blood loss. A total of 75 pediatric patients (0-14years) were included. The mean POS was 2.4 ± 1.4days, shorter than that in recent studies in China (3.3 ± 1.4days, 6 (3-16) days). None were redo, and six restenosis (8%) were improved after treatment with ureteral balloon dilatation. The mean operation time was 257.9 ± 54.4min, and blood loss was 11.8 ± 10.0ml. In the univariable analysis and multivariable analysis, no external drainage, sacral anesthesia, and withdrawal of the catheter on day one were independently associated with a POS of ≤ 2 d (p < 0.05). The implementation of this ERAS protocol for pediatric LP has resulted in a shorter length of stay without a higher readmission rate. Surgery techniques, drainage management and analgesia are the key to further improvement. ERAS for pediatric pyeloplasty should be encouraged.

Discharge optimization tool to decrease length of stay and improve satisfaction related to advanced practice provider communication

BackgroundProlonged length of stay (LOS) due to delayed hospital discharge is associated with increased patient morbidity and mortality and other poor outcomes. The length of stay (LOS) in patients undergoing elective, isolated coronary artery bypass grafting (CABG) at an urban, level 1 trauma center is 8.73 days, compared to the 7.0-day benchmark reported by the Society of Thoracic Surgeons (STS). Improving and reducing length of stay (LOS) can improve clinical, financial, and operational outcomes and decrease the costs of care for patients and the healthcare system. ObjectiveThe purpose of this quality improvement project was to implement an evidence-based discharge optimization tool (DOT) within the Electronic Health Record to reduce LOS in patients undergoing isolated CABG and enhance communication satisfaction in cardiothoracic surgery advanced practice providers (APP). MethodsWe used a DOT to communicate anticipated time to discharge in CABG patients to the multidisciplinary team. Outcomes included postoperative LOS and APP communication satisfaction. Data was obtained via chart review and statistically analyzed using a one sample T-test. Results177 patients (mean age 64 years, 72% male, 66% Caucasian) were studied. The mean postoperative LOS decreased by 16% from 8.73 days to 7.31 days (p = 0.007; Standard deviation of 3.20). Cardiothoracic surgery APP communication satisfaction improved by 33%. ConclusionsUtilization of a discharge optimization tool to communicate anticipated time to discharge can significantly decrease LOS and improve APP communication satisfaction.

Comparison Between Periarticular Analgesia Versus Intraarticular Injection for Effectiveness and Safety After Total Knee Arthroplasty

PurposeIn most studies, local infiltration analgesia (LIA) can provide better analgesic effect in the early postoperative period, but the optimal technique is unknown. Our study was designed to evaluated the early clinical efficacy and safety of periarticular analgesia versus intraarticular injection in Total knee arthroplasty (TKA). DesignA prospective study was conducted on 100 patients admitted for TKA. Subjects were divided into two groups: 50 in group A, 50 in Group B. MethodsPatients in group A received periarticular analgesia with ropivacaine 300 mg and morphine 5 mg (the drugs were diluted with saline to 50 ml) in the periosteal borders, posterior capsule and extensor apparatus and subcutaneous tissues during surgery. After stitching of joint capsule, tranexamic acid (TXA) 2 g (20 ml) was injected into the articular cavity. Group B patients had all of the 70 mL mixture (ropivacaine 300 mg, morphine 5 mg and TXA 2 g) injected intraarticularly after stitching of the joint capsule. We assessed postoperative length of stay (LOS), knee functional outcome, pain, and complications after surgery. FindingsThere was no statistical difference in visual analog scale (VAS) scores for knee pain between the two groups on postoperative day (POD)1, 3, or 30 (P > .05). Mean postoperative LOS was 7.40 ± 1.98 days in Group A, compared to 8.02 ± 2.09 days in Group B (P > .05). No significant differences between groups were seen in the mean swelling ratio (P > .05), and no significant differences were found in the Hospital for Special Surgery (HSS) knee score and range of motion (ROM) at 30 days follow-up (P > .05). There was also no statistical difference in the incidence of complications (such as superficial wound infection, deep vein thrombosis (DVT) and nausea and vomiting) between the Group A and the Group B. ConclusionsIn conclusion, it seems that intraarticular injection had a similar analgesic effect compared with periarticular injection when adopting a multi-modal analgesia regimen. Our results suggest that there is no obvious advantage with the use of periarticular injections compared to intraarticular injection. The authors believe that intraarticular injection may be a better technique compared with periarticular injections in the absence of a drainage tube because intraarticular injection can reduce the number of surgical steps and have similar postoperative outcomes.

Predicting prolonged length of stay in patients undergoing transforaminal lumbar interbody fusion.

With growing emphasis on high-value care, many institutions have been working on improving surgical efficiency, quality, and complication reduction. Unfortunately, data are limited regarding perioperative factors that may influence length of stay (LOS) following transforaminal lumbar interbody fusion (TLIF). We sought to design a predictive algorithm that determined patients at risk of prolonged LOS after TLIF. The goal was to identify patients who would benefit from preoperative intervention aimed to reduce LOS. We conducted a review of perioperative data for patients who underwent TLIF between 2014 and 2019. Univariate and multivariate stepwise regression models were used to analyze risk factor effects on postoperative LOS. Two hundred and sixty-nine patients were identified (57.2% women). Mean age at surgery was 61.7 ± 12.3years. Mean postoperative LOS was 3.08 ± 1.54days. In multivariate analysis, American Society of Anesthesiologists class (odds ratio [OR] = 1.441, 95% confidence interval [CI] 1.321-1.571), preoperative functional status (OR = 1.237, 95% CI 1.122-1.364), Oswestry Disability Index (OR = 1.010, 95% CI 1.004-1.016), and estimated blood loss (OR = 1.050, 95% CI 1.003-1.101) were independent risk factors for postoperative LOS ≥ 5days. The final model had an area under the curve of 0.948 with good discrimination and was implemented in the form of an online calculator ( https://spine.shinyapps.io/TLIF_LOS/ ). The prediction tool derived can be useful for assessing likelihood of prolonged LOS in patients undergoing TLIF. With external validation, this calculator may ultimately assist healthcare providers in identifying patients at risk for prolonged hospitalization so preoperative interventions can be undertaken to reduce LOS, thus reducing resource utilization.

Comparison of Short, Intermediate, and Long Cephalomedullary Nail Length Outcomes in Elderly Intertrochanteric Femur Fractures.

Introduction:Cephalomedullary nail (CMN) length for intertrochanteric femur fractures without subtrochanteric extension has been an ongoing debate. The authors hypothesize that increasing nail length would result in increasing surgical time, greater incidence of acute kidney injury (AKI), postoperative anemia, and blood loss requiring transfusion due to increased intramedullary reaming and pressurization of the canal with nail insertion.Methods:A retrospective chart review of patients aged 65 years or older who underwent CMN for low-energy intertrochanteric femur fractures from 2010 to 2018 was undertaken. Patient demographic data, comorbidities, case duration, postoperative hospital length of stay (LOS), and laboratory data, including serum creatinine, hemoglobin, and hematocrit, were collected for analysis. The following outcome measures were compared: postoperative pneumonia, cardiac complications, sepsis, reintubation/intensive care unit stay, pulmonary embolism, stroke, postoperative AKI, 30-day hospital readmission, 30-day return to operating room, 30-day mortality, 1-year mortality, postoperative anemia (hemoglobin <7 g/dL), and blood transfusion.Results:A total of 247 patients were analyzed (short = 48, intermediate = 39, and long = 160). No notable difference was observed in postoperative pneumonia, cardiac complications, sepsis, reintubation/intensive care unit stay, pulmonary embolism, stroke, mean total hospital LOS, mean postoperative hospital LOS, rate of postoperative AKI, 30-day readmission, 30-day return to operating room, 30-day mortality, or 1-year mortality. Patients receiving long nails had significantly higher rates of postoperative anemia (P = 0.0491), blood transfusion (P = 0.0126), and mean procedure length (P = 0.0044) compared with the two other groups.Discussion:Patients receiving long nails had markedly higher rates of postoperative anemia and blood loss requiring blood transfusion with markedly longer mean procedure length than patients receiving short and intermediate CMNs. Long nails did not result in an increase in other complications evaluated.

Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis.

Surgical correction remains the most effective treatment of patients with severe neuromuscular scoliosis (NMS). However, postoperative inpatient clinical care after spinal surgery for NMS patients is highly complex and variable, depending on the provider and/or institution. Our project used a quality improvement methodology to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery, with the global aim of decreasing postoperative hospitalized length of stay (LOS). A multidisciplinary team developed a postoperative pathway for nonambulatory patients with NMS after their primary, nonstaged corrective spinal surgery. The outcome measure was mean LOS, and the process measure was percentage compliance with the newly implemented NMS pathway. The team used statistical process control charts and measures were evaluated over 3 phases to assess the impact of the interventions over time: pretesting, testing, and sustain. The mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases. Using quality improvement methodology, we successfully standardized major components of clinical care for patients with NMS after spinal corrective surgery. Through enhanced care consistency, the mean postoperative LOS decreased by nearly 3 days and decreased LOS variability. Robust multidisciplinary involvement with key stakeholders ensured sustainability of these improvements.

Five-year outcomes of major lower extremity amputation and two-staged admission pathway for new transtibial amputees in a local hospital

Background: Transtibial amputation and subsequent prosthetic fitting can cause prolonged hospital length of stay (LOS). Recently, a two-staged admission pathway for new transtibial amputees was introduced in a local hospital to shorten hospital LOS. Methods: A retrospective cohort study was performed to review the 5-year outcomes of major lower extremity amputation in a local hospital and to compare the difference in LOS and functional outcomes between traditional (group 1) and two-staged (group 2) admission pathways for new transtibial amputees. Results: The fitting rate was 55% in transtibial amputees, 14% in transfemoral amputees, and only 3.7% in dementia patients. For new transtibial amputees, the mean postoperative LOS was significantly reduced by 32.8 days in group 2. Besides, more patients in group 2 were able to walk without aid. Conclusion: LOS for new transtibial amputees can be greatly reduced by the two-staged admission pathway to minimize hospital operational cost.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans.

BackgroundLow health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy.MethodsAdult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses.ResultsOf 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels.ConclusionsLow health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1day. The secondary outcomes included perioperative/in-hospital complications and mortality. There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4±1.5, 2.1±2.5, and 2.2±2.8days (P=0.0001), respectively, and after CAS were 1.7±2.6, 1.8±2.1, and 2±2.6days (P<0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS>1day (P=0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1day (OR 1.42, 95% CI 1.06-1.91) (P=0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P=0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P=0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P=0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P=0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Hospital-Level Medicaid Prevalence Is Associated With Increased Length of Stay After Asymptomatic Carotid Endarterectomy and Stenting Despite No Increase in Complications

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure by payers and affects hospital operating margins. Patient-level Medicaid status has been shown to be associated with longer LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. The National Inpatient Sample was queried from 2006 to 2014 for CEA and CAS performed for asymptomatic carotid stenosis. Hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM; lowest quartile), medium Medicaid prevalence (MM; second and third quartiles), and high Medicaid prevalence (HM; fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. Secondary outcomes included perioperative complications. There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Among patients who underwent CEA, 1.9%, 34.7%, and 63.4% received care at hospitals with LM, MM, and HM prevalence, respectively. Among patients who underwent CAS, 1.9%, 26.4%, and 71.8% received care at hospitals with LM, MM, and HM prevalence, respectively. Hospital-level Medicaid prevalence cohorts for CEA differed by age, sex, race, insurance, hospital size, region, neighborhood income, diabetes, and anemia (P < .05). Cohorts for CAS differed by age, race, insurance, hospital size, region, neighborhood income, illegal drug use, diabetes, and chronic renal disease (P < .05). Neurologic (0.8% vs 0.9% vs 0.9%; P = .83) and cardiac complications (0.9% vs 1.2% vs 1.2%; P = .24) after CEA were similar between hospitals with LM, MM, and HM prevalence, respectively. Neurologic (1.1% vs 1% vs 1.2%; P = .42) and cardiac complications (2% vs 1.3% vs 1.5%; P = .46) after CAS were also similar. Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5 days, 2.1 ± 2.5 days, and 2.2 ± 2.8 days (P = .0001), respectively. Mean postoperative LOS after CAS at hospitals with LM, MM, and HM prevalence was 1.7 ± 2.6 days, 1.8 ± 2.1 days, and 2 ± 2.6 days (P < .0001), respectively. On multivariable analysis for CEA, relative to LM prevalence, MM prevalence (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.17-2.24) and HM prevalence (OR, 1.66; 95% CI, 1.2-2.28; P = .009) were associated with LOS >1 day. On multivariable analysis for CAS, HM prevalence was associated with LOS >1 day (OR, 1.42; 95% CI, 1.06-1.91; P = .003). Increased hospital-level Medicaid prevalence is associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Medicaid prevalence is important in creating appropriate risk-adjusted quality metrics and developing care pathways that optimize hospital reimbursement.

Fast-track thrombolysis protocol for acute limb ischemia

ObjectiveCatheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. MethodsA retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. ResultsPrimary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. ConclusionsFTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions.

Effect of laparoscopic surgery on the risk for surgical site infections in colorectal resection: results from the Health Insurance Review & Assessment Service Database.

PurposeTo compare the hospital length of stay (LOS), duration of antibiotic use, medical costs, and incidence of surgical site infection (SSI) between laparoscopic colorectal surgery (Lap-CRS) and open CRS (Open-CRS).MethodsWe retrospectively reviewed data of the Health Insurance Review and Assessment Service Surgical Antibiotic Prophylaxis assessment (7th assessment, 2015); the nationwide data were collected from patients who underwent CRS from September to November 2015 in low volume hospital to the tertiary hospital level in Korea.ResultsAll 2,751 patients who underwent elective CRS were assessed. The mean hospital LOS (12.18 days vs. 14.16 days, P < 0.001) and mean postoperative LOS (8.21 days vs. 9.46 days, P < 0.001) were shorter in the Lap-CRS group than in the Open-CRS group. The mean duration of antibiotic use was shorter in the Lap-CRS group (2.91 days vs. 3.64 days, P = 0.033). The rate of SSI was lower in the Lap-CRS group, but there was no significant difference between the groups (3.57% vs. 5.01%, P = 0.133). Among the SSI group, the mean LOS (19.5 days vs. 24.9 days, P = 0.081), duration of antibiotic use (12.62 days vs. 15.46 days, P = 0.097), and medical costs showed no significant difference between the 2 groups.ConclusionLap-CRS is significantly associated with reduced hospital LOS and the duration of antibiotic use in this study. However, we could not identify significant differences in the incidence of SSI according to the type of surgery. To assess the overall benefits of Lap-CRS, studies including the rate of SSI up to 30 days postoperatively will be needed in the future.

Composite length of stay: An informative outcome measure in pancreatoduodenectomy combining postoperative and readmission length of stays

Presenter: Gregory Williams BS, MA | Washington University, St. Louis Background: Postoperative length of stay (PLOS) and readmission rate are pancreatoduodenectomy(PD) outcome measures. They are reported individually, although they are interrelated since short PLOS may be associated with higher readmission rates (J Surg Oncol. 2018;118:7-14 & J Oper Manag. 2019;65:1-16.) The purpose of this study was to evaluate how well a composite length of stay measure (CLOS) that included the initial length of stay and readmission length of stay describes outcomes. To do so we evaluated how well CLOS correlated to postoperative complications absolutely and compared to PLOS. Methods: 668 PDs performed at our institution from 2011-2018 were evaluated. CLOS was calculated from PLOS and readmission length of stay. Complications type and complication severity were judged using the Modified Accordion Grading System (MAGS; J Am Coll Surg. 2011;213:616-23). Multinomial logistical regression models (MLRM) were used to investigate the relationship between either PLOS or CLOS and MAGS. Multi-level and pairwise area under curves (AUC) using SAS macro %MultAUC were provided for both models. Results: 432 of 668 patients (65%) developed complications (see Table 1). 193 severe complications occurred in 154 patients, i.e., 23% of patients had one or more severe complications. The 3 most common complications were delayed gastric emptying, pancreatic fistula and postoperative anemia requiring transfusion. 177 patients (27%) were readmitted with a mean length of stay being 8.5 days (11.2 SD), with a cumulative total of 1,499 days readmitted. Mean PLOS was 10.1 days (7.1 SD) and mean CLOS was 12.3 days (10.1 SD). Spearman correlation coefficient for CLOS vs MAGS of 0.68 was higher than that of 0.49 for PLOS vs MAGS. MLRM showed that all ORs using PLOS are much lower than those using CLOS. For example, one-day increase of PLOS is associated with a 35% increase in the odds of being in MAGS grade 2 vs. no complication. However, one-day increase of CLOS is associated with a 54% increase in the odds of being in MAGS grade 2 vs. no complication. Multi-level AUC from MLRM using PLOS was 0.66 but Multi-level AUC from MLRM using CLOS was 0.71. Conclusion: CLOS provides an accurate estimate of hospital day utilization per patient for PD, reflecting not only the basal hospital recovery time for PD but the added time needed because of readmissions due to complications. It is tightly correlated to number and severity of postoperative complications. CLOS seems indicated as an additional quality measure in future studies of PD.

A Standardized Care Pathway following Mandibular Distraction in Infants Less Than 3 Months of Age

To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol. Retrospective chart review. Urban tertiary pediatric hospital. The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications. Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; P = .51). The mean postoperative LOS was 13.3 days less among infants managed with the protocol (P = .06), and the mean number of midazolam boluses was fewer among protocol patients (P < .01). A more consistent postoperative LOS, duration of mechanical ventilation, and exposure to sedating medications was observed among protocol subjects (P < .01). The LOS for 2 patients in the preprotocol group was extended due to iatrogenic withdrawal syndrome. There were no instances of accidental extubation or anoxia in either group. Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.

Trends in hospital length of stay and 30-day morbidity in pediatric patients undergoing laparoscopic ileocecal resection, 2012–2016

PurposeTo examine postoperative length of stay (LOS), hospital readmission, and 30-day complications in pediatric patients undergoing laparoscopic ileocecal resection in a contemporary cohort. MethodsRetrospective review of the American College of Surgeons National Surgery Quality Improvement Project, Pediatric (NSQIP-P) 2012–2016 participant user files for patients <19 years old who underwent laparoscopic ileocecal resection. Mean postoperative LOS, hospital readmission and both wound-specific and composite complications were calculated and compared by year of operation. Results348 patients were identified (range, 46–96 per year); 55.2–69.8% of these were admitted the day of operation, with a nonsignificant increase in frequency over the study period. Postoperative LOS ranged from 5.4 ± 2.9 days to 7.3 ± 9.1 days (p = 0.24). In subset analysis of only those patients admitted on the day of operation, postoperative LOS remained relatively long, ranging from 5.0 ± 3.0 days to 5.7 ± 4.0 days (p = 0.89). 30-day hospital readmission proportions rose insignificantly, from 6.9% in 2012 to 15.5% in 2016 (p = 0.41). Wound complication rates (including superficial, deep, and deep organ space infections, as well as wound dehiscence) ranged from 0.0% to 8.6%, but did not vary in a statistically significant manner. Nonwound complication rates were vanishingly small. ConclusionsPostoperative LOS in pediatric patients undergoing laparoscopic ileocecal resection in a select group of patients cared for in hospitals participating in NSQIP-P has not decreased in the past 5 years despite emerging evidence of the safety and relevance of enhanced recovery after surgery programs. Opportunities for shortening LOS without compromising patient safety may still exist. Level-of-evidenceIII Retrospective comparative study.

Pre- and intra-operative predictors of postoperative hospital length of stay in patients undergoing radical prostatectomy for prostate cancer in China: a retrospective observational study

BackgroundHospital length of stay (LOS) has recently been receiving increasing attention as a marker of medical resource consumption. Identifying predictors of longer LOS can better equip doctors to counsel patients and facilitate more efficient patient flow and utilization of medical resources. The objective of this study was to identify pre- and intra-operative risk factors for postoperative hospital LOS in patients who had undergone radical prostatectomy in China.MethodsWe retrospectively analyzed data of 793 eligible patients with prostate cancer who had undergone radical prostatectomy in our institution between January 2011 and March 2016. Relevant preoperative variables, including patient characteristics, medical comorbidities, prostate cancer disease-specific variables, urinary tract symptoms, preoperative laboratory values, and intraoperative variables including operation type, operation duration, and blood loss, were analyzed. The outcome was postoperative length of stay which was calculated as the time from the date of operation to the date of discharge. Multiple linear regression analysis was used to identify predictors of this outcome.ResultsThe mean postoperative LOS was 11.7 days (±4.6 days) and the median 10 days (range, 5–46 days). According to univariate and multivariate analysis, operation type (open or laparoscopic), blood loss, Gleason score (≥8) and preoperative laboratory values of white blood count (WBC) were found to be the main explanatory predictors of postoperative LOS of patients with prostate cancer in our institution. Additionally, open surgery was the strongest significant predictor of longer LOS according to the standardized coefficients in this model.ConclusionsOur findings indicate that significant predictors of longer postoperative LOS in patients who have undergone radical prostatectomy in China include both preoperative variables of Gleason score, WBC and intraoperative variables of operation type (open or laparoscopic), blood loss. To shorten hospital LOS in patients with prostate cancer and optimize utilization of Chinese medical resources, efforts should be made to improve the intraoperative process and reduce the prevalence of preoperative risk factors.