Postoperative Inpatient Hospital Research Articles

Rethinking hospital postoperative resource use: A national analysis of pediatric appendectomy patients admitted to children’s hospitals

BackgroundThe increased use of remote monitoring and telemedicine support may help alleviate the need for some of the postoperative inpatient hospital care and reduce health care costs, but little is known about current postoperative hospital resource use patterns. We aim to describe hospital resources use patterns in pediatric patients postappendectomy for complicated appendicitis and to evaluate the potential of earlier discharge with remote monitoring. MethodsThis was a retrospective cohort study using the Pediatric Health Information System database for patients who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Health care use/costs (antibiotics, intravenous fluids [proxy for diet], analgesics, laboratory studies, and imaging tests) were determined using administrative billing data. Potentially avoidable days were defined as nondischarge days without codes for intravenous opioid pain medication or intravenous fluids. Descriptive statistics and logistic regression were used. ResultsIn total, 24,165 patients were included: 8,300 patients (34.3%) had at least 1 potentially avoidable hospitalization day, totaling 13,970 days or 14.2% of all hospitalization days. Median hospitalization cost was $19,434 [$15,658–$25,157], with accommodation and operating room being the greatest contributors. Public insurance and minority races and ethnicities were associated with greater odds of potentially avoidable days. More than 80% of hospitalized patients had intravenous antibiotics through 10 days postoperatively. More than 20% received opioids daily. ConclusionsMore than one third of the patients who underwent laparoscopic appendectomy for complicated appendicitis could have had at least 1 potentially avoidable hospitalization day. Remote monitoring and telemedicine support should be explored and could help with earlier discharge and lower costs.

Use of sugammadex is associated with reduced incidence and severity of postoperative nausea and vomiting in adult patients with obesity undergoing laparoscopic bariatric surgery: a post-hoc analysis

BackgroundPostoperative nausea and vomiting (PONV) is a common but troublesome complication in patients who undergo laparoscopic bariatric surgery (LBS). Whether sugammadex use is related to the persistent decrease in the occurrence of PONV during postoperative inpatient hospitalization, which is critical for the rehabilitation of patients after LBS, remains unknown.MethodsThe study was based on a randomized controlled trial conducted in an accredited bariatric centre. A total of 205 patients who underwent LBS were included in the analysis. Univariate analysis and multivariable logistic regression model were used to identify the significant variables related to PONV. Then propensity score matching and inverse probability of treatment weighting (IPTW) were employed to compare outcomes between the sugammadex and neostigmine groups. The primary outcome was the incidence of PONV within 48 h after LBS. The secondary endpoints included the severity of PONV, time to first flatus, need for rescue antiemetic therapy, and water intake.ResultsThe incidence of PONV was 43.4% (89/205) within the first 48 h after LBS. In multivariable analysis, sugammadex use (OR 0.03, 95% CI 0.01–0.09, P < 0.001) was an independent protective factor of PONV. After IPTW adjustment, sugammadex use was associated with lower incidence of PONV (OR 0.54, 95% CI 0.48–0.61, P < 0.001), postoperative nausea (PON) (OR 0.77, 95% CI 0.67–0.88, P < 0.001), and postoperative vomiting (POV) (OR 0.60, 95% CI 0.53–0.68, P < 0.001) within postoperative 48 h. The severity of PON as well as the incidence and severity of POV within the first 24 h were also lower in the sugammadex group (all P < 0.05). Reduced need for rescue antiemetic therapy within the first 24 h, increased water intake for both periods, and earlier first passage of flatus were observed in the sugammadex group (all P < 0.05).ConclusionsCompared with neostigmine, sugammadex can reduce the incidence and severity of PONV, increase postoperative water intake, and shorten the time to first flatus in bariatric patients during postoperative inpatient hospitalization, which may play a pivotal role in enhanced recovery.Trial registrationChinese Clinical Trial Registry (ChiCTR2100052418, http://www.chictr.org.cn/showprojen.aspx?proj=134893, date of registration: October 25, 2021).

Complications of delayed and newborn primary closures of classic bladder exstrophy: Is there a difference?

The authors aim to compare single institutional 30-day complication rates between delayed and neonatal closure of classic bladder exstrophy (CBE). An institutional database of 1415 exstrophy-epispadias patients was reviewed retrospectively for CBE patients who underwent primary closures at the authors' institution between 1990 and 2020. Patients were identified as having received either neonatal or delayed (at age >28 days) closures. All 30-day complications were recorded, including wound infection and dehiscence, genitourinary and non-genitourinary infections, bowel obstruction, blood transfusions, and others. Descriptive statistics were performed to summarize patient level data. Categorical variables were reported by count and percentages and were compared using Exact Cochran-Armitage trend analysis by decade, or with Fisher's Exact Test and Chi-square test when directly comparing categories and outcomes. Continuous variables were analyzed via Mann Whitney U and one-way ANOVA as appropriate. The cohort included 145 patients: 50 delayed and 95 neonatal closures. The total complication rate was 58% in delayed closures compared to 48.4% for neonatal closures (p=0.298), with the majority being Clavien-Dindo grade I or II. Excluding blood transfusion, complication rates fell to 26% and 34.7% in delayed and neonatal closures, respectively (p=0.349). The most common single complication was unplanned post-operative blood transfusion (38% delayed; 26.3% neonatal; p=0.34), followed by pyelonephritis (2% delayed; 8.4% neonatal), and urinary fistula (6% delayed; 1.1% neonatal). Grade III Clavien-Dindo complications occurred in 2% delayed and 7.4% neonatal groups (n=1; n=7 respectively; p=0.263). A single delayed patient had grade IV complications compared to three neonatal patients (p=0.66). Delayed primary closure has become a frequently performed alternative in the modern treatment of bladder exstrophy for patients who do not undergo newborn closure because of prohibitive circumstances or surgeon's discretion. The majority of the complications associated with delayed closure are a low Clavien-Dindo grade and easily managed during the postoperative inpatient hospital stay. Families should be counseled about the possibility of minor, conservatively managed complications and likelihood of a blood transfusion with osteotomy.

Should total thyroidectomies be performed by high-volume endocrine surgeons? A cost-effectiveness analysis.

The increased experience of a thyroid surgeon reduces the risk of postoperative complications. However, whether it is also cost-effective is currently unknown. The aim of the present study was to compare cost-effectiveness of high-volume (HVS) with low-volume surgeons (LVS) when performing a total thyroidectomy. This was a retrospective study, comparing the mean cost of a total thyroidectomy per patient, between HVS and LVS. This included the cost of surgical procedure and pre- and post-operative inpatient hospitalization. A threshold of 25 thyroidectomies/year was used to discriminate between HVS and LVS. Four-hundred and forty-one patients were classified into HVS and 342 into the LVS group. With regard to surgical complications, higher rates of temporary hypoparathyroidism and endangered airway were observed in the LVS than in the HVS group. The estimated total cost per patient was higher in the LVS compared with the HVS group [€1721 ± 396 ($1910 ± 439) versus €979 ± 68 ($1086 ± 487); p < 0.0001]. This cost remained higher when sub-analysis was performed for each surgical stage, involving either surgical procedure or pre- and post-operative inpatient hospitalization. Differences between LVS and HVS mainly involved the cost in surgical procedure (23% attributed to occupation of the operating room) and postoperative inpatient hospitalization (45% of the total thyroidectomy cost). Total thyroidectomy performed by a HVS seems to be cost-effective compared with the one conducted by LVS. This is mostly attributed to the lower rates of surgical complications, such as postoperative hypoparathyroidism and airway obstruction.

Opioid Consumption Rate After Foot and Ankle Surgery

Category:Opioid consumption rate and risk factors investigation after foot and ankle surgeryIntroduction/Purpose:The rapid increase in the consumption of prescription opioids has become one of the leading medical, economical, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among surgical specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopaedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures, and to identify patient risk factors associated with higher use.Methods:A total of 535 patients who underwent a F&A surgery performed by one orthopedic surgeon from August 2016 to March 2018 were investigated. The study was approved by our IRB. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the two-week postoperative visit, the patient-reported amount of consumed opioids was recorded. Prescription details, the amount of opioids taken, refill requests, pain-issue related telephone calls, and additional MD/ED visits were also documented. Patient demographics and co-morbidities, use of regional anesthesia, postoperative inpatient hospitalization, surgery type and severity, and pre-operative opioid use were collected retrospectively. Total amounts of morphine equivalents were calculated and converted into oxycodone 5 mg pills for standardization. P-values of <0.05 were considered significant.Results:Two hundred forty-four patients with a mean age of 50 years (±16.3) and a BMI of 29 (±6.1) were included. Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure. 225 (92.2%) patients received regional block. Patients reported that they consumed only 51.2% of prescribed pills after a bony procedure and 42.4% after a soft tissue procedure, respectively, which resulted in a total of 4,496.2 left over pills that derived from this study amongst only 244 patients enrolled. There were 11 refill requests (4.5%), two (0.8%) additional MD/ED visits, and 19 (7.8%) telephone calls related to pain. BMI, procedure type, and number of opioids prescribed were positively correlated with the consumption rate (P =.002, P<.001, P<0.001, respectively).Conclusion:BMI, surgery type (bony vs. soft tissue), and a higher number of pills dispensed were correlated with higher use in the postoperative period. After an educative discussion on postoperative pain, patients took 42.4% of the prescribed opioid after soft tissue procedures and 51.2% after bony procedures, resulting in a significant number of unused pills now available to the community. Future guidelines are necessary to improve our postoperative pain management, but this study suggests that current amounts of dispensed pills after orthopaedic F&A procedures are approximately twice as high as necessary.

Correlation Between 24-Hour Predischarge Opioid Use and Amount of Opioids Prescribed at Hospital Discharge

ImportanceThe United States is experiencing an opioid abuse epidemic. Opioid overprescription by physicians may contribute to this epidemic.ObjectivesTo determine if there was a correlation between a postoperative patient’s 24-hour predischarge opioid use and the amount of opioids prescribed at hospital discharge and to determine the number of patients who used no opioids prior to discharge but were still prescribed opioids after hospital discharge.Design, Setting, and ParticipantsThis cross-sectional study performed a retrospective record review of 18 343 postoperative patients at Boston Medical Center and Lahey Hospital and Medical Center–Burlington Campus who were discharged home after a postoperative inpatient admission of at least 24 hours. Data collection spanned from May 22, 2014, to June 30, 2016, in the Boston Medical Center data set and from March 23, 2015, to September 7, 2016, in the Lahey Hospital and Medical Center–Burlington Campus data set.ExposuresSurgery requiring a postoperative inpatient hospital stay longer than 24 hours.Main Outcomes and MeasuresThe main outcome measures were the patient’s 24-hour predischarge opioid use and the total quantity of opioids prescribed at hospital discharge. Potential overprescription was defined as the number of patients who used no opioids in the 24 hours prior to hospital discharge but were still prescribed opioids after hospital discharge.ResultsAmong the 18 343 patients (10 069 women and 8274 men; mean age, 52.2 years) who underwent 21 452 surgical procedures, there was wide variation in the amount of opioids prescribed at hospital discharge given a postoperative patient’s 24-hour predischarge opioid use. A total of 6548 patients (35.7%) used no opioids in the 24 hours prior to hospital discharge; however, 2988 of these patients (45.6%) were prescribed opioids at hospital discharge, suggesting potential overprescription. Services that had the highest rates of potential overprescription (obstetrics [adjusted odds ratio (AOR), 3.146; 95% CI, 2.094-4.765] and gynecology [AOR, 2.355; 95% CI, 1.663-3.390], orthopedics [AOR, 0.943; 95% CI, 0.719-1.242], and plastic surgery [AOR, 0.733; 95% CI, 0.334-1.682]) generally had the highest rates of patients still using opioids at hospital discharge. Pediatric surgery was the only service that did not have any cases of potential overprescription (AOR, 2.09 × 10−7; 95% CI, 0.000-0.016).Conclusions and RelevanceOpioids are not regularly prescribed in a patient-specific manner to postoperative patients. Potential opioid overprescription occurs regularly after surgery among almost all surgical specialties.

Use of Chronic Methadone Before Total Knee Arthroplasty

BackgroundA subset of patients who undergo total knee arthroplasty (TKA) are on methadone maintenance. They require more and often unpredictable quantities of opioids to function as effective painkillers. This study aims to compare the opioid requirements and the immediate postoperative course for patients on methadone maintenance with those who are not, after a TKA. MethodsA retrospective, case-control study was performed. From 2005 to 2010, 36 patients, who underwent a unilateral TKA, on chronic methadone maintenance were identified. A control group matched for age, gender, and body mass index comprised patients from the same period, who did not self-report taking methadone. Chart review and analysis of patient demographics, type of anesthesia used, preoperative methadone use, inpatient opioid use (converted to oral morphine equivalent doses), need for in-house pain management consult, length of hospital stay, and need for reoperation were performed. ResultsPatients on chronic methadone maintenance used significantly more opioids than patients not on methadone during their entire inpatient stay (P < .001). This was demonstrated by a higher median daily usage of opioids and higher patient-controlled analgesia usage. Patients on methadone maintenance had a significantly longer postoperative inpatient hospitalization (P < .001). Finally, these patients required significantly more inpatient pain management referrals (P = .025). ConclusionThere is a significantly higher opioid requirement, length of stay, and pain management consults in patients on methadone maintenance compared with those who are not after a TKA. These patients may benefit from a nonroutine approach to perioperative care in TKA.

Complications Following Inpatient Extracapsular Tonsillectomy in Children 36 Months and Younger.

Tonsillectomy is among the most common surgical procedures performed by general and pediatric otolaryngologists. Inpatient surgery is generally recommended for children 36 months and younger owing to concern for a higher incidence of postoperative complications. To ascertain the need for a planned inpatient stay for extracapsular tonsillectomy in children 36 months and younger. Retrospective medical record review of patients 36 months and younger who underwent inpatient extracapsular tonsillectomy or adenotonsillectomy at a tertiary care academic institution from January 2009 to September 2014. Of 279 medical records reviewed, 188 met the inclusion criteria for the study. Extracapsular tonsillectomy. Inpatient notes, discharge summaries, and postoperative clinic visit notes in the electronic medical record were reviewed for information about complications occurring during postoperative inpatient hospitalization. Specifically, the incidence of postoperative hemorrhage, postoperative pulmonary edema, oxygen desaturation to less than 90% requiring supplemental oxygen overnight, overall poor oral intake, poor oral intake leading to prolonged hospitalization exceeding 1 day, return to the operating room, and mortality were determined. The 188 patients in the study ranged in age from 18.3 to 35.9 months (mean, 29.5 months). Among the patients, 183 (97.3%) underwent surgery for sleep-disordered breathing, 2 (1.1%) were reintubated for postobstructive pulmonary edema, 1 (0.5%) experienced a self-limited postoperative hemorrhage, 5 (2.7%) required supplemental oxygen postoperatively, and 30 (15.9%) had poor oral intake postoperatively on the day of surgery. The hospital stay for 9 patients (4.8%) exceeded 1 day because of poor oral intake. No patients had to return to the operating room during their hospitalization and there were no deaths of patients in the population studied. Very few children experienced postoperative complications during their hospitalization, suggesting that outpatient tonsillectomy and adenotonsillectomy may be safe in children in this age group. Overnight hospitalization of children in this age group may not always be necessary after an appropriate period of postoperative observation.

A barrier retractor to reduce surgical site infections and wound disruptions in obese patients undergoing cesarean delivery: a randomized controlled trial

Surgical site infections (SSIs) are an important cause of morbidity following cesarean delivery, particularly in obese patients. Methods to reduce SSIs after cesarean delivery would have an important impact in obese obstetric patients. The purpose of this study was to determine whether the Alexis O cesarean delivery retractor, a barrier self-retaining retractor, reduces SSIs and wound disruptions in obese patients undergoing cesarean delivery. This was a randomized controlled trial of obese women (body mass index ≥ 30 kg/m(2)) undergoing nonemergent cesarean delivery. Patients were randomized to the treatment group (using the Alexis O cesarean delivery retractor) or to the control group (using conventional handheld retractors). The primary outcome was SSI or wound disruption during the 30 day postoperative period. Secondary outcomes included operative time, estimated blood loss, change in hemoglobin, antiemetic use, length of postoperative hospital stay, hospital readmission, and other postoperative complications. A total of 301 patients were enrolled in the study. One hundred forty-four patients were randomized to the treatment group and 157 to the control group. Baseline characteristics and indications for cesarean delivery were similar between the 2 groups. Median body mass index was 40.1 kg/m(2). There were no significant differences between the treatment and the control group in the primary outcome of SSI or wound disruption rates at the 30 day assessment (20.6% vs 17.6%, P = .62), during the postoperative inpatient hospitalization or at the 1-2 week postoperative visit. There were also no differences in the primary outcome when adjusting for obesity class or thickness of the subcuticular layer. Patients in the treatment group had lower rates of uterine exteriorization (54.3% vs 87.3%, P < .001), but there were no differences in all other outcomes. Use of the Alexis retractor in cesarean delivery deliveries did not decrease SSI or wound disruption rates in an obese population. Its use as a retractor should be left to the discretion of the surgeon and clinical circumstances.

Correlation between sleep disruption on postoperative pain.

To identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting, determine the relationship between sleep disruption and the quantity of narcotics taken for postoperative pain, and determine if hospital length of stay is related to sleep disruption. Prospective cohort study. Single tertiary care academic institution. Fifty patients undergoing total hip or knee arthroplasty at Henry Ford Hospital in Detroit, Michigan, between January 2013 and November 2013 were asked to wear an actigraph during their postoperative hospital stay. Total sleep time, sleep efficiency, awake index, total narcotic use, visual analog pain scores, and postoperative complications were analyzed. Overall sleep efficiency was 61.2% and 66.5% with an awake index of 5.5 and 5.4 for each of the postoperative nights measured. A significant correlation was found between increased self-reported pain scores and decreased total sleep time (r = -0.31; P = .03). Spearman correlations between total sleep time, sleep efficiency, and awake index were made with narcotic use on postoperative day (POD) 0 and 1. Longer hospital length of stay was significantly correlated with decreased sleep efficiency (r = -0.35, P = .01). Complication rates were not statistically different compared with sleep parameters. Better control of a patient's pain is associated with greater sleep efficiency and total sleep time. Improvements in sleep efficiency in hospitalized patients may be associated with a decrease in length of stay.

The Effect of Sleep Disruption on Postoperative Pain

Objectives: (1) Identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting. (2) Determine the relationship between sleep disruption and the use of postoperative narcotic for pain. (3) Determine if the postoperative hospital course is impacted by sleep disruption. Sleep disturbance is a common complaint among hospitalized patients. Decreased sleep and poor sleep quality have been found to be correlated with poor hospital outcomes and decreased wound healing. Methods: Prospective cohort study. Fifty patients undergoing total hip or knee arthroplasty at Henry Ford Hospital in Detroit, Michigan, between January 2013 and November 2013 were asked to wear an actigraph during their postoperative hospital stay. Total sleep time, sleep efficiency, awake index, narcotic use, visual analog pain scores, and postoperative complications were analyzed. Results: A significant correlation was found between lower self-reported pain scores and total sleep time ( P =.03). Spearman correlations between the number of minutes of sleep, sleep efficiency, and awake index were made with the narcotic use on postoperative days (PODs) 0 and 1. None of the results were statistically significant. Narcotic use on POD 0 and sleep on POD 1was marginally significant ( P = .09). Longer hospital stay was associated with decreased sleep efficiency ( P = .01). Complication rates were not statistically different when compared to other sleep parameters. Conclusions: Better control of a patient’s pain improves sleep efficiency and total sleep time. Attention to decreased sleep disruption for hospitalized patients has the potential to improve patient satisfaction with hospital care and decrease length of stay.

Doctor-patient communication in surgery: attitudes and expectations of general surgery patients about the involvement and education of surgical residents

BACKGROUND: Education is a major function of academic medical centers. At these teaching institutions residents provide a substantial amount of care on medical and surgical services. The attitudes of patients about the training of surgical residents and the impact of residents on patients’ perceptions of care in a surgical setting are unknown. STUDY DESIGN: Patients admitted to the gastrointestinal surgery service completed a 30-item survey designed for this study. Patients included in the study underwent operations and had a postoperative inpatient hospital stay. We analyzed patients’ answers to determine frequency and correlations among answers. RESULTS: Two hundred patients participated in the study during a 7-month period between July 1999 and January 2000. A majority of patients were comfortable having residents involved in their care (86%) and felt it was important to help educate future surgeons (91%). Most did not feel inconvenienced by being at a teaching hospital (71%) and felt they received extra attention there (74%). Patients were more willing to participate in resident education if they expected to have several physicians involved in their care, felt that they received extra attention, or if the teaching atmosphere did not inconvenience them. Despite the stated willingness of patients to help with surgical resident education, 32% answered that they would not want residents doing any of their operation. CONCLUSIONS: Surgical resident education is well received and considered important by patients. Patient orientation to the resident education process is vital to patients’ perceptions of care and may render patients more willing to participate in educational activities.