Rate Of Same-day Discharge Research Articles

Readmission Rates in Robotic Gynecologic Surgery: A Comparison between Inpatient and Outpatient Surgery in a Large Health System

<h3>Study Objective</h3> Current literature suggests that same-day discharge (SDD) after minimally invasive gynecologic surgery (MIGS) is feasible and associated with better perioperative outcomes. This study aims to evaluate how rates and reasons for readmission after robotic gynecologic surgery evolved over a four-year period in a large hospital system following an increase in SDD. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Health system including 11 academic and community hospitals. <h3>Patients or Participants</h3> 6,170 patients undergoing robotic gynecologic surgery during 2017-2020. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> In this study, 6,170 patients underwent robotic gynecologic surgery between 2017-2020. 3,316 patients were discharged the same day of surgery (outpatient, OP) and 2,854 were discharged on or after postoperative day 1 (inpatient, IP). 118 total patients were readmitted with a readmission rate of 3.2%. When stratified into IP and OP, the readmission rates were 4.8% and 2.3%, respectively. Over the 4-year period, the rate of SDD as a percentage of total robotic gynecologic surgeries increased by 28.3% with 59% SDD in 2020. We observed the lowest overall rate of readmission during 2020, which was also the year with the highest rate of SDD. When stratified for readmission indications, 2020 also accounted for the lowest incidence of readmission for venous thromboembolism and genitourinary complications compared to prior years. There were no readmissions for wound dehiscence or post-operative pain in this year. The rates of readmission for infection, hemorrhage, and gastrointestinal complications in 2020 were comparable to prior years in which SDD rates were lower. <h3>Conclusion</h3> As rates of SDD increased between 2017-2020, the readmission rate after robotic gynecologic surgery decreased. When stratified for specific indications, all rates for readmission in 2020 (the highest SDD year) were comparable or lower than previous years. Our study supports the current literature which demonstrates that SDD after MIGS is both safe and feasible.

COVID19 Pandemic Impact on Same-Day Discharge Rates after Minimally Invasive Surgery for Endometrial Cancer

Study ObjectiveTo determine if the COVID19 pandemic increased the rate of same-day discharge (SDD) after minimally invasive surgery (MIS) for endometrial cancer.DesignRetrospective cohort study of patients undergoing MIS hysterectomy for endometrial cancer for the six months before and after the COVID19 restrictions went into place on March 17, 2020.SettingRobotic or laparoscopic procedure in the low dorsal lithotomy position. Arms were tucked and padded at their sides.Patients or Participants166 patients underwent a MIS procedure for the indication of endometrial cancer at a large, academic institution from September 1, 2019, through October 1, 2020. 80 patients prior to the implementation of the COVID19 restrictions and 86 patients after.InterventionsCOVID19 pandemic with visitor restrictions and hospital policy changes placed on March 17, 2020.Measurements and Main ResultsSDD rate was increased following the start of the COVID19 pandemic (40% vs 58%, p= 0.02). There were no differences between the two groups in regard to operative time (p= 0.07), estimated blood loss (EBL) (p= 0.21), uterine weight (p= 0.12), age (p= 0.06), BMI (p=0.42), or surgery start time (p= 0.15). In a multivariable logistic regression model, subjects in the post COVID19 group had a 3.08 (95% CI: 1.40, 6.74, p= 0.01) higher odds of SDD than those in the pre COVID19 group. There was no difference in 30-day readmission rates (7.5% vs 5.8%, p=0.66).ConclusionWith no additional interventions from a surgical standpoint, the start of the COVID19 pandemic improved SDD rates. The reason for this is speculative but may be related to patient and physician desire to keep patients out of the hospital and may provide further evidence that subjective reasons lead to an increase in hospital length of stay.

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

PurposeWe investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward.Methods200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period.Results166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%.ConclusionIntroduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review.

Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts. The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05. Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use. Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA. Level IV; systematic review.

Office-based transnasal oesophagoscopy: Evaluating the safety, efficacy and application in head and neck cancer patients.

Transnasal Oesophagoscopy (TNO) is an approach to inspect the upper aerodigestive tract, especially in the head and neck cancer (HNCA) population that present with dysphagia. Twenty-five (25) office-based TNO procedures were performed, with a same-day discharge rate of 96% (24/25) and no reported complications. This case series is the first to compare preoperative and postoperative outcomes (EAT-10) following stricture dilatation using TNO in the UK. Our results show a statistically significant improvement in symptom severity (EAT-10 scores) (n=11, P=0.001). Nearly half (45.5%) of patients undergoing dilatation developed strictures due to post-radiation/post-laryngectomy complications.Biopsy in 4/5 patients was sufficient fordiagnosis/ruling out disease. Of these patients, 5/5 had a previous HNCA. This study identifies the remit for a new 'one-stop' TNO service for suspected cancer referrals, of which a large proportion are patients with a previous HNCA. Surveillance, therapeutics and diagnostics can be achieved in a single visit. Earlier staging or treatment may be achieved due to a fast turnover in clinic.

MP64-13 ROBOT ASSISTED RADICAL PROSTATECTOMY IN THE COVID-19 ERA: IMPLEMENTATION OF SAME DAY DISCHARGE PROTOCOL USING ENHANCED RECOVERY AFTER SURGERY PRINCIPLES

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VI (MP64)1 Sep 2021MP64-13 ROBOT ASSISTED RADICAL PROSTATECTOMY IN THE COVID-19 ERA: IMPLEMENTATION OF SAME DAY DISCHARGE PROTOCOL USING ENHANCED RECOVERY AFTER SURGERY PRINCIPLES Kassem Faraj, Samantha Wilder, David Mauler, Adri Durant, Elisabeth Lim, Lanyu Mi, and Scott Cheney Kassem FarajKassem Faraj More articles by this author , Samantha WilderSamantha Wilder More articles by this author , David MaulerDavid Mauler More articles by this author , Adri DurantAdri Durant More articles by this author , Elisabeth LimElisabeth Lim More articles by this author , Lanyu MiLanyu Mi More articles by this author , and Scott CheneyScott Cheney More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002104.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has impacted the ability to treat patients with prostate cancer due to increases in COVID-19 related hospital admissions and limited hospital bed availability. Same-day discharge (SDD) has previously been established as safe in patients who undergo robot assisted radical prostatectomy (RARP). We present our experience in implementing a SDD protocol using enhanced recovery after surgery (ERAS) principles. METHODS: This is a retrospective review that included all patients who underwent RARP at our institution between 06/01/2019 and 07/01/2020. Patient were stratified into two cohorts based on when COVID-19 restrictions were implemented at our institution: Pre COVID-19 era (06/01/2019-02/29/2020) and COVID-19 era (03/01/2020-07/01/2020). During the COVID-19 era, we implemented a protocol that supported SDD by minimizing opioid use, encouraging ambulation immediately after surgery, and early oral intake. Success of SDD was assessed and perioperative complications were compared between the cohorts. RESULTS: In 283 prostatectomies performed at our institution during this review, 83 (29.3%) were performed during the COVID-19 era. The pre COVID-19 era contained more patients who had cT1 disease (56.0% vs 20.5%) and less patients with >cT3 (10.5% vs 30.1%, p<0.001). Same-day discharge was successfull in 29 (34.9%) of patients in the COVID-19 era vs 13 (6.5%) in the pre COVID-19 era (p<0.001). In the most recent 3 months at our institution, SDD rates have continued to increase to 67.4%, with 100% success in the most recent month. Overall complication rates, including hospital readmission, emergency department visits, and telephone calls after surgery did not differ between cohorts (p>0.05). CONCLUSIONS: We present practice changes that permitted the surgical management of prostate cancer patients to continue in an era where hospital bed capacity is limited by using ERAS protocols to rapidly and safely increase the SDD rate after surgery. Implications of such changes can be significant on the institutional and healthcare system level. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1115-e1115 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kassem Faraj More articles by this author Samantha Wilder More articles by this author David Mauler More articles by this author Adri Durant More articles by this author Elisabeth Lim More articles by this author Lanyu Mi More articles by this author Scott Cheney More articles by this author Expand All Advertisement PDF downloadLoading ...

Outpatient Total Hip and Knee Arthroplasty Performed in a Safety Net Hospital System.

Introduction:High-percentage outpatient total joint arthroplasty (TJA) performed in a safety net hospital system has not been described. A rapid recovery protocol (RRP) was instituted at our safety net hospital that allowed eventual transition to outpatient TJA.Methods:Retrospective review of all primary total knee and hip arthroplasty performed by a single surgeon (RR) using an RRP was performed. The initial cohort of patients was monitored overnight with the goal of next-day discharge (n = 57), and as the RRP evolved, the subsequent cohort of patients had the possibility of same-day discharge (PSDD, n = 61). Outcome measures included the rate of same-day discharge in the PSDD cohort and short-term adverse event rates.Results:In the PSDD cohort, 86.9% (n = 53) of patients were successfully discharged on the day of surgery, and hospital length of stay was decreased by 17.7 hours (13.5 versus 31.2 hours, P < 0.0001). Comparing the next-day discharge and PSDD groups, no significant differences were found in 30-day emergency department visits (5.3% versus 3.3%, P = 0.67), 90-day complications (15.8% versus 13.1%, P = 0.79), 90-day readmissions (0% versus 3.3%, P = 0.50), or 90-day revision surgeries (0% versus 3.3%, P = 0.50).Conclusions:This study demonstrates that the transition to outpatient TJA can be successfully performed in a safety net hospital system without increasing short-term adverse events.

Comprehensive perioperative care program to improve same-day discharge after minimally invasive gynecologic oncology surgery (MIGOS)

<h3>Objectives:</h3> Same-day discharge (SDD) after minimally invasive hysterectomy for benign or malignant gynecologic conditions has been shown to be safe and feasible, but remains challenging to implement. We designed and implemented a quality improvement perioperative program for minimally invasive gynecologic oncology surgery (MIGOS). Our aim was to improve SDD rate from 30% to 75% over the study period, while maintaining acceptable 30-day perioperative outcomes and patient experience. <h3>Methods:</h3> Consecutive patients undergoing minimally invasive hysterectomy at a single cancer centre were included during the 9-month project period and a historical cohort of 100 consecutive patients was identified for comparison. A team of gynecologic oncologists, anesthesiologists, and nurses developed a comprehensive perioperative care program and met bi-weekly to revise interventions through plan-do-study-act (PDSA) cycles. Patients were followed for 30 days after discharge. We conducted a descriptive analysis of the characteristics of pre-MIGOS and MIGOS patient cohorts using Wilcoxon rank-sum or Fisher exact tests. We used a run chart to monitor effects of interventions on outcomes and a pre-post analysis to evaluate for statistical significance of change in SDD and perioperative outcomes. <h3>Results:</h3> We assessed 100 consecutive pre-MIGOS and 79 consecutive MIGOS patients. Overall SDD rates increased from 31% (31/100) to 71% (56/79) after implementation (p<0.001) (Figure 1). There was a consistent increase in SDD rate after implementation, although more pronounced following the start of the COVID pandemic. The MIGOS cohort was significantly younger (59 vs. 65; p=0.04) and had shorter operative times (168 vs. 202 minutes; p<0.001) but the two groups were not different with respect to BMI, comorbidity, stage distribution, type of procedure performed, and intraoperative blood loss. We found no difference in 30-day perioperative complication rates, readmission, reoperation, clinic visits, emergency department visits, mortality or morbidity. The most common reason for overnight admission was nausea and vomiting (35%), complications related to pre-existing comorbidities (15%) and urinary retention (10%). Overall, 89% of MIGOS patients rated their experience as ‘very good' or ‘excellent', and 87% felt that their post-operative length of stay was adequate. <h3>Conclusions:</h3> Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, a multidisciplinary team significantly improved SDD rates while maintaining low 30-day perioperative complications and excellent patient experience.

Same-day discharge after robotic hysterectomy for gynecologic malignancy: a study of cost analysis and resource utilization

Objectives: To determine impact and cost savings of a quality intervention involving enhanced patient, provider, and staff education focused on same day discharge after robotic assisted total hysterectomy, and/or bilateral salpingo-oophorectomy with sentinel and/or additional lymph node dissection. Methods: A quality project was undertaken at our institution to improve the rate of same day discharge after robotic assisted hysterectomy and to assess the resource utilization savings of such an intervention. Literature supports feasibility and safety of same day discharge for robotic assisted hysterectomies alone or with other procedures for benign and malignant indications. Complex robotic assisted hysterectomies include bilateral salpingo-oophorectomy plus sentinel or additional lymph node resection. We collected historical data via chart review for the 12 months of 2018 (Group A) to determine our baseline same day discharge rate for complex robotic hysterectomies. Faculty, outpatient clinic and perioperative clinic staff were provided with education regarding the same day discharge goal for complex robotic assisted hysterectomies for patients from a single institution in our gynecologic oncology practice. We then prospectively collected the outcome data on patients undergoing complex robotic hysterectomies for the subsequent 12 months in 2019 (Group B). We compared demographic, clinical factors, and factors of resource utilization such as time in surgery and recovery and length of admission. Descriptive statistics and t-test were utilized to compare the groups. Results: One hundred three patients underwent complex robotic assisted hysterectomy in 2018, and 5% (5 patients) were discharged home on the day of surgery (Group A). One hundred twelve patients underwent complex robotic assisted hysterectomy in 2019 (Group B), and 32% (36 patients) were discharged home on the day of surgery. There was no significant difference between mean age (62 vs 64) or BMI (37 vs 36) in the two cohorts, respectively. Median length of stay was 21 hours for patients that were not discharged on day of surgery and 3.5 hours for patients discharged day of surgery. Of the 41 total patients undergoing same day discharge (Group A + Group B), there was one urgent care visit, one ER visit and and no readmissions in 30 days post procedure. A savings of approximately $1975 per case when patient discharged day of surgery. By promoting same day discharge after robotic assisted hysterectomy, 648 in-patient care hours were saved during the 12 months post intervention. Conclusions: A low cost patient and provider education initiative to increase same day discharge after robotic hysterectomy in gynecologic oncology patients positively impacted cost and resource utilization without negatively impacting readmission rates and ER utilization. In 12 months, the same day discharge rate in one facility was increased from 5% to 32% of robotic hysterectomy cases.

Less is more: clinical utility of postoperative labs following minimally invasive hysterectomy for endometrial cancer

<h3>Objectives:</h3> With the Increasing rates of same day discharge following minimally invasive endometrial cancer (EC) surgery, the need for and value of routine postoperative testing is unclear. We determined whether routine postoperative labs following minimally invasive hysterectomy for EC led to clinically significant changes in postoperative care. <h3>Methods:</h3> This was a single-institution retrospective cohort study of patients undergoing minimally invasive hysterectomy for EC by a gynecologic oncologist. A random sample was selected from an existing database of patients who underwent surgery for EC between June 2014-2017. Patient demographics, preoperative comorbidities, operative and postoperative data, and pathologic findings were manually extracted from the patients' medical records. The financial burden of laboratory evaluation was computed using hospital-level cost data. <h3>Results:</h3> Of the 266 women included in the analysis, the majority (91.4%) were White, with a mean age of 61.5 years, and mean BMI of 38.0±10.1kg/m². The most common comorbidities were diabetes (29.3%, n=78), chronic pulmonary disease (7.9%, n=21), and renal disease (3.8%, n=10). The mean operative time was 152.1±37.8 minutes and mean EBL was 105±91.7mL. Most patients (66.5%, n=177) underwent LAD, of which 77.4% had sentinel (n=78) and/or complete pelvic LAD (n=128), and an additional 42.4% (n=75) underwent paraaortic lymph node assessment. All patients had post-operative labs ordered: 100% complete blood count, 99.2% chemistry, 55.3% magnesium, 44.7% phosphate, 39.8% calcium, 3.4% PT/PTT/INR, 1.9% liver function tests, and 15% other. The mean pre- and post-operative hemoglobin was 13.5±1.4g/dL and 11.5±1.3g/dL, respectively. Mean pre- and post-operative creatinine were 0.83±0.21mg/dL and 0.78±0.20mg/dL. Thirteen patients (4.9%) had a change in management due to postoperative lab results (Table 1). Of these, only two patients (0.8% of entire cohort) had no symptoms or change in clinical status that would have otherwise prompted labs to be performed: one received a blood transfusion for asymptomatic anemia and the other electrolyte repletion for asymptomatic hypomagnesemia of 1.2mg/dL. There were no preoperative or operative factors significantly associated with a postoperative change in management due to labs, postoperative creatinine or postoperative hemoglobin. Routine postoperative laboratory evaluation in this cohort increased hospital costs by $118,455 or approximately $445 per patient. <h3>Conclusions:</h3> Routine postoperative labs are unlikely to lead to significant changes in management for women undergoing minimally invasive hysterectomy for EC, and may increase cost without providing a discernable clinical benefit. In the setting of strict post-operative guidelines, laboratory tests should be ordered when clinically indicated rather than as part of routine postoperative management for women undergoing minimally invasive hysterectomy for EC.

Trends in Use and Outcomes of Same-Day Discharge Following Elective Percutaneous Coronary Intervention.

The aims of this study were to describe trends and hospital variation in same-day discharge following elective percutaneous coronary intervention (PCI) and to evaluate the association between trends in same-day discharge and patient outcomes. Insights on contemporary use of same-day discharge following elective PCI are limited. In a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017, overall and hospital-level trends in same-day discharge were assessed. Among the 212,369 patients who linked to Centers for Medicare and Medicaid Services data, the association between same-day discharge and 30-day mortality and rehospitalization was assessed. A total of 114,461 patients (14.0%) were discharged the same day as PCI. The proportion of patients with same-day discharge increased from 4.5% in the third quarter of 2009 to 28.6% in the fourth quarter of 2017. From 2009 to 2017, the rate of same-day discharge increased from 4.3% to 19.5% for femoral-access PCI and from 9.9% to 39.7% for radial-access PCI. Hospital-level variation in the use of same-day discharge persisted throughout (median odds ratio adjusted for year and radial access: 4.15). Risk-adjusted 30-day mortality did not change over time, while risk-adjusted rehospitalization decreased over time and more quickly for same-day discharge (P for interaction<0.001). In the past decade, a large increase in the use of same-day discharge following elective PCI was not associated with worse 30-day mortality or rehospitalization. Hospital-level variation in same-day discharge may represent an opportunity to reduce costs without compromising patient outcomes.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway.

We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

Factors Associated with Same Day Discharge after Laparoscopic Surgery in Gynecologic Oncology

To identify factors associated with same day discharge (SDD) after laparoscopic surgery in gynecologic oncology. Retrospective cohort. Teaching hospital. Total of 800 patients having minimally invasive surgery in the division of gynecologic oncology during a 20-month period. Minimally invasive surgery cases were reviewed for determinants of SDD to identify factors that could improve the SDD rate. During the study period, 800 minimally invasive procedures were performed with a 43.0% SDD rate. Patients who had SDD were younger (52.3 years vs 58.0 years; p <.001), had a lower body mass index (31.1 kg/m2 vs 33.7 kg/m2; p <.001), were less likely to have a malignancy (28.2% vs 55.5%; p <.001), had a lower estimated blood loss (36 vs 72 mL; p <.001), and were more likely to have received an enhanced recovery after surgery protocol (49.8% vs 39.3%; p <.003). Total surgical time was shorter in women with SDD (156 minutes vs 208 minutes) as was total narcotic use in morphine equivalents (MEq) (milligram intravenous MEq, 23.1 mg MEq vs 28.8 mg MEq). SDD was also associated with earlier start time (p <.001). Laparoscopic cases were most likely to have SDD (51.4%) as compared with robotic assisted surgery (16.1%) or minilaparotomy (10.5%). There was a wide range of SDD among surgeons ranging from 19.8% to 56.2% (p <.001). In a multivariate analysis, the factors predicting SDD in order of predictive factors were surgical time (p <.001), recovery time (p <.001), start time (p <.001), surgeon (p <.001), age (p <.001), estimated blood loss (p <.001), and type of surgery (p=.005). Multiple factors affect SDD. Modifiable factors for SDD include the start time, surgeon preference, and patient expectations for SDD. Given these data, centers should prioritize surgical order by which patients are more likely to go home, and surgeons should analyze their own data with respect to achieving higher SDD rates.

Enhanced Recovery and Same-Day Discharge After Minimally Invasive Sacrocolpopexy.

The objective of this study was to evaluate whether an enhanced recovery after surgery (ERAS) protocol was associated with a higher rate of same-day discharge after robot-assisted or laparoscopic sacrocolpopexy and to describe the safety and feasibility of same-day discharge after these procedures. A historical control, retrospective cohort study of women undergoing minimally invasive sacrocolpopexy comparing rates of same-day discharge before and after implementation of an ERAS protocol was conducted. Secondary outcomes were obtained by comparing women discharged the same day with those discharged postoperative day ≥1, including postoperative complications and unplanned postoperative patient encounters within 30 days of surgery. Logistic regression was performed to control for potential confounders. Of the 166 women identified (83 before ERAS implementation; 83 after ERAS implementation), 43 underwent same-day discharge versus 123 admitted overnight. The rate of same-day discharge increased 28 percentage points after ERAS implementation (12% vs 40%, P < 0.01). Compared with women admitted overnight, same-day discharge women had shorter procedures (154 vs 173 minutes, P = 0.01), spent longer time in the postanesthesia care unit (130 vs 106 minutes, P = 0.01), and were more likely to be discharged with a Foley catheter (58% vs 28%, P < 0.01). After multivariable logistic regression analysis, ERAS was associated with increased odds of same-day discharge (odds ratio, 4.91; 95% confidence interval, 2.17-11.09). There were no differences in unplanned postoperative patient contacts or postoperative complications within 30 days between same-day discharge and overnight admission groups. Implementation of an ERAS protocol for minimally invasive sacrocolpopexy was associated with a 3-fold increase in same-day discharge.

Same-day discharge across FPMRS surgical cases is safe and feasible: A 10-year single-surgeon experience.

Enhanced recovery after surgery protocols and increased attention to value-based care have led to the reconsideration of routine postoperative admission in female pelvic medicine and reconstructive surgery (FPMRS) cases. We aimed to assess trends in same-day discharge (SDD) and associated readmissions and emergency room visits in a single-surgeon 10-year experience. The electronic medical record was queried for 30-day outcomes (readmission and emergency department visits with associated indications) for all cases performed between June 2010 and August 2020 by a single FPMRS surgeon. Non-FPMRS specialty cases were excluded. Patient characteristics and 30-day outcomes were compared based on SDD status for the overall cohort as well as the subset of cases traditionally involving an overnight stay (i.e., robotic transabdominal, apical prolapse repair). 1793 surgeries were identified and analyzed, including 357 apical prolapse repairs, 370 slings, 392 neuromodulation and 114 complex mesh excisions. The majority (79.1%) had SDD. For admitted patients, mean length of stay was 1.5 (1.3) days. Among cases traditionally involving overnight stay, rates of SDD were significantly higher in 2020 than 2010 (84% vs. 32%, p < 0.001), and increased over time. Overall rates of 30-day readmission and ED visits were low (1.9% and 2.6%, respectively) and did not differ based on SDD status (p = 0.76). Readmissions occurred at mean 11.6 (7.0) days, most commonly for urinary tract infection (13/34). SDD is not associated with increased 30-day readmission or ED visits across a wide breadth of FPMRS cases. SDD is safe and feasible in the majority of FPMRS cases.

Same-day discharge vs. observation after laparoscopic pediatric appendectomy: a prospective cohort study.

Through 2015, the practice at our university based free-standing children's hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis. Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables. Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P<0.0001). Same-day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. This study found no differences in outcomes between the timing of discharge, with a significantly lower cost of stay for patients discharged home the same day.

Outpatient stereotactic brain biopsies.

Outpatient neurosurgery is rising popularity leading to patients’ satisfaction and cost-savings. Although several North-American teams have shown the safety of outpatient stereotactic brain biopsies, few data from other countries with different health care systems are available. We therefore conducted a feasibility and safety study on the outpatient stereotactic brain biopsies. We prospectively examined all the consecutive stereotactic brain biopsies performed in an outpatient setting at our tertiary medical center, between June 2018 and September 2020. Among the 437 patients who underwent stereotactic brain biopsy during the study period, 40 (9.2%) patients were enrolled for an outpatient management. The sex ratio was 1 and the median age on biopsy day was 55 [41–66] years. The median distance from patients’ home to hospital was 17 km [3–47]. 95% of patients had pre-biopsy ASA score of 1 or 2 and mRs equal to 2 or less. The rate of same-day discharge was 100%. No patient experienced post-biopsy symptomatic complication necessitating readmission within the month following the biopsy. One patient (2.5%) resorted to an unplanned consultation. Histological findings obtained from brain biopsy led to a diagnosis in all patients; the most frequently found were neoplastic lesions (77.5%). Stereotactic brain biopsies can therefore be safely achieved on an outpatient setting in carefully selected patients. This process could be more widely adopted in other neurosurgical centers, without affecting the quality of patient’s health care and safety. In this article, we propose management guidelines and pre-biopsy checklist for performing ambulatory stereotactic brain biopsies.

A COVID-19 Pivot Plan to Resume Elective Surgeries at the Hartford Healthcare Connecticut Orthopaedic Institute.

BackgroundThe Connecticut Orthopaedic Institute (COI) conceptualized a Pivot Plan during an elective surgery moratorium at the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic with the goal of planning and executing orthopedic procedures safely. With the resumption of elective surgeries and the continued planning of surgical recovery over the months (and possibly years) to follow, facilities must brace themselves for repeat waves of COVID-19. Thereby, herein we share the Pivot Plan, its implementation process, evaluation of patient safety, and program performance during a pandemic. This could inform the efforts of other institutions seeking to restart non-emergent surgeries during similarly trying times in the future. MethodsThe COI formed a multidisciplinary team of leaders that met weekly to design a Pivot Plan and a dashboard to guide the resumption of surgeries and assess the performance of the Pivot Plan. The plan revolved around four domains: safety, space, staff, and supplies. It was implemented in two COI-affiliated facilities: MidState Medical Center (MMC) and St. Vincent’s Medical Center (SVMC). Monthly metrics from May to November 2020 were compared to the six-month averages for the pre-pandemic baseline period from September 2019 to February 2020.ResultsThe total number (N) of elective orthopaedic cases prior to the pandemic pre-COVID averaged 372 cases per month for MMC and 197 cases for SVMC. During the pandemic post-COVID, N averaging at 361 for MMC and 243 for SVMC illustrates COI was able to perform elective surgeries amid a worsening pandemic. Same-day (SD) discharge rates for total joint arthroplasty (TJA) pre-COVID averaged 8% for MMC and 3% for SVMC. Post-COVID, the SD average was 16.7% for MMC and 11.4% for SVMC. This data indicates that orthopaedic providers were cognizant of length of stay in order to reduce the risk of in-hospital exposure to COVID-19. The 30-day readmission (30R) rate for TJA pre-COVID averaged 1.4% for MMC and 2.7% for SVMC. A high level of care and follow-up is reflected in a lower average 30R post-COVID, 1.1% for both MMC and SVMC. Transitions for TJA patients to their home settings after surgery also reflect the quality of care and the efficiency of the patient throughput process with necessary precautions in place. Post-COVID, the patient transition to home (T) averaged 98.1% for MMC and 97.5% for SVMC compared to T = 96.8% for MMC and 88% for SVMC pre-COVID. No patients experienced deep vein thrombosis or pulmonary embolism during the time period of the project. Positive COVID-19 diagnosis 23 days after discharge was 0% at MMC and 0.2% at SVMC.ConclusionThe COI Pivot Plan was successfully implemented at two different hospitals offering elective orthopaedic surgeries to a varied patient population. The precautions taken by COI were effective in controlling the spread of the SARS-CoV-2 virus while returning to elective orthopaedic surgery. Furthermore, data collected before and after the onset of the COVID-19 pandemic indicated that program performance and quality improved.

Readmissions and perioperative outcomes for same-day versus next-day discharge after prolapse surgery.

We aimed to evaluate the safety of same-day discharge (SDD) compared with next-day discharge (NDD) after prolapse surgery on a national level hypothesizing that readmission and complication rates after SDD would not be higher than NDD. We performed a retrospective cohort study using the National Surgical Quality Improvement Program database including 2014-2018. Current Procedural Terminology (CPT) codes were used to identify minimally invasive apical suspensions or obliterative procedures. Exclusion criteria were length of stay > 1day, unrelated concomitant procedures, serious medical comorbidities, American Society of Anesthesiologists (ASA) Class >2, and complication during index admission. The primary outcome was 30-day readmission, and secondary outcomes included 30-day complications. 12,583 were included in analysis. SDD rate was 16.7%. The majority of women were white (91%) with a mean age of 59years and mean body mass index of 28kg/m². Medical comorbidities were similar between the SDD and NDD groups. Overall incidence of 30-day readmission was 1.7%. SDD had lower odds of 30-day readmission than NDD (aOR 0.63, 95% CI 0.41-0.98). SDD had lower odds of 30-day complications but this failed to reach statistical significance (aOR 0.67, 95% CI 0.44-1.03). In this cohort, 30-day readmission and complication rates were not higher after SDD compared to NDD in women undergoing minimally-invasive apical suspension or obliterative procedures. We interpret these findings carefully given study limitations but believe our findings support the safety of SDD after minimally invasive apical suspension or obliterative procedures in a low-risk population.

Same-Day Discharge Following Holmium Laser Enucleation in Patients Assessed to Have Large Gland Prostates (≥175 cc).

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for large glands (≥175 cc) are associated with prolonged length of stay (LOS) and postoperative catheterization. However, advances in laser technology combined with surgical technique optimization have early evidence supporting same-day discharge. We look to examine contemporary same-day discharge outcomes for large glands. Materials and Methods: With Institutional Review Board (IRB) approval we queried our electronic medical record and retrospective clinical registry to examine perioperative outcomes of large gland (≥175 cc) prostates that underwent HoLEP with consideration for same-day discharge. Results: From December 10, 2019 to September 29, 2020 we identified 55 patients with a preoperative prostate size ≥175 cc (39 CT, 12 MRI, 4 transrectal ultrasound), of which 45 were scheduled for same-day discharge and 10 for admission. Mean preoperative prostate size was 229.9 cc (range 175-535 cc) and 36 (65.5%) were in urinary retention. Mean preoperative prostate-specific antigen (PSA) was 8.58 ng/mL, American Urological Association Symptom Score (AUASS) 22.3, and Qmax 8.8 mL/second. At 3 months postoperative follow-up mean AUASS was 6.7, PSA 0.87 ng/mL and Qmax 20.4 mL/second. All comer same-day discharge rate was 70% (38/55). Of patients planned for same-day discharge 38/45 (84%) were effective. Average LOS for all patients was 11.8 hours with catheterization of 21.2 hours. When compared with 2010 published large gland outcomes, our current LOS represents a 220% reduction. Looking specifically at patients planned for same-day discharge, average LOS and catheter duration was 8.8 and 17.0 hours, whereas LOS and catheter duration for patients planned for admission was 25.7 and 39.4 hours, respectively. Conclusions: We report the first outcomes of preoperatively planned same-day discharge for HoLEP in large glands (≥175 cc). A combination of technologic advances and optimization of technique have allowed for a safe adoption of same-day discharge, providing additional advantages over alternative large gland treatments.