Same-day Discharge Research Articles

Same-day discharge after elective open arterial surgery

ObjectiveTo evaluate the feasibility of same-day discharge (SDD) after open peripheral arterial surgery (OAS) in a veteran population. MethodsThis is a single-center, retrospective study. Starting September 2021, veterans who underwent elective OAS were selectively chosen for planned SDD. Eligible procedures included popliteal artery aneurysm repair, common femoral/superficial femoral/popliteal artery endarterectomy ± concurrent endovascular intervention, bypass graft revision, femoral-femoral bypass, and axillofemoral bypass. All patients who underwent eligible procedures were compared across three eras based on the primary location of postoperative admission: intensive care unit era (ICUE, September 2016-December 2018), inpatient ward era (WARDE, January 2019-August 2021), and SDD era (SDDE, September 2021-December 2022). Demographics, comorbidities, indication for procedures, operative times, complications, readmissions, and length of stay (LOS) were analyzed. ResultsNinety-nine male patients underwent eligible procedures during the 6-year study period (ICUE: 32, WARDE; 41, and SDDE: 26). ICUE had higher rates of tobacco use (P = .04) with no differences in age or other comorbidities between the eras. Indications were claudication, bypass graft stenosis, popliteal aneurysm, ischemic rest pain, and tissue loss. Twenty patients were selected for SDD, and 18 were successfully discharged same day. Operative times were not significantly different between the eras. SDDE patients were more likely to undergo monitored anesthesia care (P = .04). The mean LOS was significantly lower in SDDE (0.54 days, P < .001) compared with WARDE (2.9 days) and ICUE (2.8 days). The mean ICU LOS was lower in SDDE (0.2 days, P <.001) compared with ICUE (1.1 days). There was no difference in postoperative complications (P = .30), reoperation (P = .51), or readmission rates (P = .35). ConclusionsSDD is safe and feasible after elective OAS in a veteran population with a low unplanned admission rate.

Safety of same-day discharge without anticoagulation for left-sided radiofrequency catheter ablations in pediatrics

BackgroundFor left-sided radiofrequency catheter ablation (LCA) in pediatrics, significant practice variability exists regarding anticoagulation and discharge practices. Given the lack of data in pediatric patients, the risks and benefits of these practices are not well defined. ObjectiveThe purpose of this study was to evaluate the safety of same-day discharge and use of aspirin (ASA) in pediatric patients following LCA. MethodsWe performed a retrospective cohort study of pediatric patients who underwent LCA from 2010 to 2020 at our institution. Discharge timing and ASA usage were based on operator preference. The primary outcome was incidence of postablation anticoagulation complications reported within 1 month of the procedure. ResultsThree hundred seventy-six patients underwent LCA and met inclusion criteria. Median [25th, 75th percentiles] age was 13.9 [10.5, 16.2] years; 18 (4.7%) had a history of structural heart disease. The most common substrates for ablation were Wolff-Parkinson-White syndrome (183 patients [48.7%]), concealed accessory pathway (159 patients [42.3%]), and ectopic atrial tachycardia (10 patients [2.7%]). Three hundred thirty-eight patients (89.9%) were discharged on the day of LCA. Seventy-six patients (20.2%) were prescribed ASA at discharge. Of those who underwent follow-up (273 patients [72.6%]), 7 (2.7%) reported an anticoagulation complication (5 with hematoma, 2 with headache). One of these patients was prescribed ASA; none required readmission. There was no correlation between anticoagulation complications and same-day discharge or with ASA usage. ConclusionGiven the rare incidence of anticoagulation complications in pediatric patients undergoing LCAs, same-day discharge from the electrophysiology laboratory without anticoagulation should be considered.

Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System

Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.

Review of efficacy and safety of same-day discharge after percutaneous nephrolithotomy

Review of efficacy and safety of same-day discharge after percutaneous nephrolithotomy

A 10-Year Retrospective Review of Playground-Associated Craniofacial Injuries in the Pediatric Patient Population.

This retrospective study utilized the National Electronic Injury Surveillance System (NEISS) database to identify pediatric emergency department (ED) patients with playground-associated craniofacial injuries between January 2012 and December 2021. A total of 25 414 patients were identified. The majority of injuries occurred in preschool and elementary school-age children (90.3%) and patients were more commonly boys (59.3%). Injuries most often involved the head/scalp (52.4%), face (30.4%), and mouth (11.9%). Infant (32.7%) and teen (40.0%) injuries most commonly involved swings, whereas preschool (23.1%) and elementary school (28.1%) injuries were mostly associated with slides and climbers, respectively. Most patients were treated in the ED and discharged to home (96.5%), a small portion required hospitalization (1.6%), and one death was reported. Although the majority of the injuries were relatively minor and resulted in same-day discharges, these injuries can result in serious physical harm, emotional stress, and unexpected financial burdens. Proper education and supervision regarding safe play is important to prevent these injuries.

Patient Perceptions of Same-Day Discharge Versus Overnight Stay After Total Joint Arthroplasty: Results of a Survey.

In the COVID-19 era, there has been increasing interest in same-day discharge (SDD) after total joint arthroplasty (TJA). However, patient perception of SDD is not well reported. We sought to understand patients' perceptions and preferences of postoperative care by surveying patients who have completed both an overnight stay (ONS) and an SDD after TJA. We emailed survey links to 67 patients who previously underwent either 2 total hip arthroplasties (THAs) or 2 total knee arthroplasties (TKAs). Fifty-two patients (78%) responded to the survey. Thirty-four (65%) patients underwent staged, bilateral TKAs, and 18 (35%) patients underwent staged, bilateral THAs. Overall, 63% of patients preferred their SDD, 12% had no preference, and 25% preferred their ONS, with no difference in preference between TKA and THA groups. Those who preferred their SDD reported being more comfortable at home. Those who preferred their ONS felt their pain and concerns were better addressed. No differences were found in comfort, sleep quality, appetite, burden on family, return to function, feelings of being discharged too soon, overall experience, 30-day emergency department (ED) visits, or readmissions within 30 days between patients' SDD and ONS. There was a small statistically significant difference between patients' perception of safety between SDD and ONS. Our survey found that most patients reported a preference for SDD after TJA over ONS. Although there was a small difference in patient perception of safety, there were no differences in return to the ED or readmissions after SDD and ONS.

Identifying Preoperative Predictors for 24-Hour Discharge After Elective Hip and Knee Arthroplasties.

Introduction The resumption of elective medical services post-pandemic has brought to the forefront the importance of outpatient arthroplasty services in promoting efficiency and mitigating hospital-acquired infections. This study aimed to identify preoperative factors that predict the success of outpatient lower limb arthroplasty surgeries. Methods Our investigation involved a retrospective review of 606 patients who underwent elective hip and knee arthroplasty. We documented variables such as the hospital length of stay, patient demographics (age and gender), Oxford Joint Scores, body mass index, socioeconomic status, American Society of Anaesthesiologists' (ASA) physical status classification, comorbid conditions, the Functional Comorbidity Index (FCI), preoperative blood test results, implant types, scheduling details of the surgery, and rates of readmission within 30 days post-surgery. A two-step analysis using univariate and multivariate regression models was performed to pinpoint preoperative indicators that could predict same-day discharge following arthroplasty. Results Forty-five patients (7.4%) were discharged within 24 hours of surgery. Early discharge did not correlate with higher rates of readmission within 30 days (p>0.05). Neither weekend nor afternoon surgeries significantly extended the length of stay beyond 24 hours (p>0.05). No significant differences in the prevalence of comorbidities, FCI scores, socioeconomic status, or preoperative blood test results were found when comparing patients discharged within 24 hours to those who stayed longer. Multivariate analysis revealed that patients younger than 65 years (relative risk (RR) 2.41; 95% confidence interval (CI) 1.02-5.74) and those receiving partial knee arthroplasty (RR 8.91; 95% CI 3.05-26.04) were more likely to be discharged within 24 hours. Conclusions Outpatient arthroplasty is a viable option, especially for individuals younger than 65 years undergoing partial knee arthroplasty, independent of other patient-related factors, comorbidities, and specifics of the hospital episode.

The impact of patient activation on the effectiveness of digital health remote post-discharge follow-up and same-day-discharge after elective colorectal surgery.

Low patient activation (PA) is associated with worse postoperative outcomes, however, its impact on the effectiveness of digital health interventions is unknown. We sought to determine the impact of PA on the effectiveness of digital health application for remote post-discharge follow-up for patients undergoing elective colectomy. Data analysis included a control cohort (CC) of patients undergoing elective colorectal surgery from 10/2017 to 04/2018 without the digital health intervention and a digital application cohort (DAC) that received a smart phone application for remote post-discharge follow-up from 03/2021 to 08/2022, including a subset of same-day discharge (SDD) patients. PA was measured using the Patient Activation Measure (PAM; score 0-100) and categorized into low (< 55.1) and high (≥ 55.1). The PAM was administered 4-6weeks before surgery in the DAC group and on postoperative day (POD) 1 in the CC group. The main outcome measure was 30-day emergency department (ED) visits. A total of 164 patients were included (89DAC with 50 SDD, 75CC), with no differences in patient characteristics other than more stoma closures in the DAC group. Overall, 77% of patients had high PA level, with no difference between CC and DAC (77% vs. 81%, p = 0.25). There was no difference in ED visits between CC and DAC (19% vs. 18%, p = 0.90). Overall, low PA was associated more ED visits (29% vs 14%, p = 0.04). In the SDD subgroup, low PA patients had more ED visits (38% vs. 7%, p = 0.015). PA level did not affect app usage metrics. On multiple regression, only low PA remained independently associated with ED visits (OR 3.42, 95%CI 1.27, 9.24). Low PA remains an important predictor of surgical outcomes after elective colorectal surgery regardless of the use of a digital health application for remote post-discharge follow-up. This suggests that improving PA levels may improve postoperative outcomes.

Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study

BackgroundSpinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). MethodsWe took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). ResultsAll spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). ConclusionsBoth spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. Level of EvidenceLevel 3, Retrospective Cohort Comparison.

Safety and Outcomes of Same-Day Discharge Versus Overnight Observation After Transradial Percutaneous Coronary Intervention: A Retrospective Cohort Study in a Tertiary Hospital in Philippines

INTRODUCTION: Since earlier days of percutaneous coronary intervention (PCI), there has been improvement in several aspects of PCI including use of transradial approach and third-generation drug-eluting stents. Despite data showing its safety, same-day discharge (SDD) PCI has not been widely practiced in our institution and country. At present, there are no published studies from the Philippines showing the safety and outcome of SDD PCI. OBJECTIVES: The primary objective of this study is to determine and compare the safety and outcomes of SDD versus overnight observation after PCI in The Medical City from 2018 to 2021. METHODS: This was a retrospective cohort study. The primary endpoint was to describe and compare the clinical profile of patients who underwent same-day versus overnight observation after PCI such as age, sex, comorbidities, indication for coronary angiogram, procedure time, total dye used, stent, and drug-eluting stent used. Incidence of major adverse cardiovascular event, mortality, readmission, and access site complications were also determined at 48 hours and 30 days after PCI. RESULTS: Ninety-three patients were included in the analysis. Reasons for undergoing PCI were a positive noninvasive stress test (45%), stable angina (40%), coronary artery disease (26%), and heart failure (20%). More single-vessel (60%) than multivessel (40%) PCIs were performed. The most frequently affected coronary artery was the LAD (82%), followed by right coronary artery (32%) and left circumflex artery (30%). Compared with patients who stayed longer after PCI, the SDD group had lower mean (±SD) body mass index (25.10 ± 3.12 vs 28.55 ± 4.95 kg/m2), less due to a positive noninvasive test (26% vs 51%), more who underwent a single-vessel PCI (78% vs 54%), lower median amount of injected dye (130 vs 188 mL), shorter median procedural time (74 vs 101.5 minutes), and greater use of sirolimus-eluting stent (22% vs 3%). No adverse outcome of interest was noted in any patient up to 30 days after hospital discharge. CONCLUSION: No adverse outcome was noted with SDD PCI. Larger, prospective, randomized comparative studies are needed to ascertain its safety before recommending SDD PCI routinely. KEYWORDS: left anterior descending artery, left circumflex artery, percutaneous coronary intervention, right coronary artery, same-day discharge

Feasibility of same-day discharge after laparoscopic sleeve gastrectomy in the Netherlands.

There is a trend towards laparoscopic sleeve gastrectomy (SG) with same-day discharge (SDD), as an efficient healthcare pathway to alleviate the burden on clinical capacity. This approach seems to be safe, if patients are carefully selected. In our bariatric center, a protocol for Roux-en-Y gastric bypass with SDD has already been successfully implemented. The aim of this study was to evaluate feasibility of applying the same SDD protocol for SG. A single-center prospective feasibility study was conducted at a high-volume bariatric center. Low-risk patients who were scheduled for primary SG were included. Strict criteria were used for approval upon SDD. The primary outcome was the rate of successful SDD without readmission within 48h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality. Fifty patients were included in the study, of whom 45 were successfully discharged on the same day of the surgery. Nausea and vomiting were the most common reasons for overnight hospitalization (three patients). One patient was readmitted within the first 48h due to a mild complication related to bleeding, resulting in a success rate of 88% for SDD without readmission within 48h. No severe complications or mortality were reported in the cohort. Our SDD protocol for SG has demonstrated feasibility, with a high success rate of SDD and no severe complications. Strict conditions should be met for the safe implementation of a SDD protocol, including careful patient selection and the establishment of a safety net to detect early complications.

Safety and feasibility of same-day discharge following uncomplicated transvenous lead extraction.

Transvenous lead extraction (TLE),while mostly a safe procedure, has risk of serious periprocedural complications. As such, overnight hospitalization remains a routine practice. In our center, we routinely discharge patients on the same day following an uncomplicated TLE. This is a retrospective study of 265 consecutive patients who underwent uncomplicated TLE in our center between 2019 and 2021. Same-day discharge (SDD)patients are compared with those who stayed at least overnight for observation after the TLE procedure (non-SDD group). To assess the safety of an SDD strategy after uncomplicated TLE, the main study endpoint was to compare the rate of major procedure-related complications at 1-, 7-, and 30-days. To identify the factors influencing the operator's decision to discharge the patient on the same day, the secondary endpoint was to analyze clinical and procedural predictors of SDD. A total of 153 patients were discharged the same day after uncomplicated TLE (SDD),while 112 stayed at least overnight after the procedure (non-SDD).There was no significant difference in major procedure-related complications at 1-day (SDD0% vs. non-SDD 1.8%, p value = ns), while patients in the SDD group had a lower rate of 7- and 30-day complications when compared with those in the non-SDD group (2.1% vs. 8.2%, p value = .0308; and 3.5% vs. 16%, p value = .0049, respectively). Noninfectious indication for TLE (OR16.1, 95% confidence interval[CI] 4.29-77.6) and procedure end time before 12:00 (OR2.82, 95% CI 1.11-7.27) were the only independent predictors of SDD. SDD discharge following uncomplicated TLE in selected patients (i.e., those without device infection and when the TLE procedure is completed in the morning) is feasible and safe.

Comorbid Factors and Selection for Same-Day Total Joint Arthroplasty.

Given that the number of total joint arthroplasties (TJAs) performed worldwide is expected to continue to increase, and there are significant costs associated with these procedures, selecting candidates for same-day or 23-hour discharge is important in lowering costs and providing greater access. Younger, healthier patients are excellent candidates for same-day discharge after TJA. Preoperative medical assessment can help exclude patients who may not be candidates, such as patients with 1 or more comorbidities that increase the risk of intra- and postoperative complications and who may require a longer period of monitoring.

Same-day discharge after craniotomy for tumor resection: a retrospective observational single-center study of 630 patients.

Modern neurosurgical developments enable minimally invasive surgery with shorter operation times, faster recovery, and earlier hospital discharge. These in combination with Enhanced Recovery After Surgery (ERAS) protocols have the potential to safely shift craniotomy for tumor resection to the ambulatory setting in selected patients. The aim of this retrospective observational single-center study was to assess the success rate of planned same-day discharge from hospital in patients undergoing craniotomy for supratentorial brain tumor resection under general anesthesia or awake craniotomy as well as to explore potential associations with anesthesia techniques, complications, and readmission rates. A retrospective analysis of all patients scheduled for same-day discharge after supratentorial craniotomy for tumor resection over 25 years (1996-2021) was performed. Patients were identified for same-day discharge based on specific inclusion and exclusion criteria. Data collected included patient demographics, comorbidities, anesthetic data, perioperative complications, and patient dispositions. Data are presented descriptively. A total of 630 patients (mean age 50.9 years; 311 females, 319 males) scheduled for same-day discharge were analyzed. Patients underwent either awake craniotomy (AC; n = 491) or craniotomy under general anesthesia (GA; n = 139). Successful preplanned same-day discharge occurred in 571 (90.6%). Failed same-day discharge happened in 59 patients (GA, n = 14; AC, n = 45). Reasons for failed discharge included the following: new neurological deficit (n = 28); presence of seizure (n = 8); postoperative nausea and vomiting (PONV; n = 12); excessive headache (n = 5); and/or social factors (n = 10). Nine patients (1.4%) (GA, n = 0; AC, n = 9) with same-day discharge required readmission to hospital within the first 24 hours after discharge. Reasons for readmission included headache (n = 2), seizure (n = 4), neurological deficit (n = 3), and/or PONV (n = 1); all patients were successfully discharged from hospital after 1 day with no need for reoperation. This retrospective, single-center analysis shows that same-day discharge after craniotomy can be safe in carefully selected patients after both GA and AC for tumor resection. Multidisciplinary involvement (surgeons, anesthesiologists, nurses, and other allied health professionals) optimizes success of same-day craniotomy programs. Future optimization of analgesia and prevention of PONV has the potential to increase the success rate.

Same-day discharge after craniotomy for brain tumor resection: enhancing patient selection through a prognostic scoring system.

Neurosurgery, among other surgical fields, is amid a shift in patient management with enhanced recovery and same-day discharge (SDD) protocols slowly becoming more popular and feasible. While such protocols reduce the risk of nosocomial complications and improve patient satisfaction, appropriate patient selection remains an area of debate. The authors aimed to better quantify selection criteria through a prospective follow-up study of patients undergoing brain tumor resection with SDD. Three arms of analysis were carried out. First, clinical data of SDD patients were prospectively collected between August 2021 and August 2022. In parallel, a retrospective analysis of patients who qualified for SDD but were excluded at surgeon clinical discretion over the same period was performed. Third, a comparative analysis of the pilot and follow-up studies was done from which a clinical scoring system for patient selection was derived. Over the duration of the study, 31 of 334 patients were selected for SDD while 59 qualified for SDD by previously defined criteria but were not selected at the surgeon's discretion. There was no difference in outcomes between the two groups, and there were no postoperative complications among the SDD group within 30 days of surgery. Preoperative clinical characteristics found to be significantly different between the two cohorts (left-sided lesion, extra-axial pathology, prior treatment of brain tumor, and tumor volume ≤ 11.75 cm3) were included in a predictive scoring system for successful SDD. The scoring system was found to significantly predict high or low likelihood for successful SDD when tested on the mixed prospective cohort. This study provides a straightforward clinical scoring system for appropriate selection of candidates for SDD after craniotomy for brain tumor resection. This clinical tool aims to aid clinicians in appropriate admission course selection and builds on the growing literature surrounding same-day and outpatient cranial neurosurgery.

Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with Hospital-at-Home-based postoperative follow-up.

The objective of this study was to describe the outcomes of outpatient oncological neurosurgery (OON) in a European clinical setting and to compare them with the conventional inpatient protocol. Patients who had undergone OON (either tumor removal or biopsy) at the authors' center since 2019 were analyzed. A matched cohort of patients was selected from patients undergoing tumor surgery in the same period. Collected data included patient demographics, postoperative progress, specific location of the target lesion, and the procedure performed. There were 18 patients in the case group and 59 patients in the control group. The outpatient surgeries had a same-day discharge rate of 89%, and all ambulatory patients successfully completed the Enhanced Recovery After Surgery program within 6.24 hours of the procedure. All ambulatory patients underwent Hospital-at-Home postoperative follow-up for an average of 4.12 days. Radiological complications were present in 11% of the case group and 8% of the control group. Postoperative neurological deficit occurred in 6% of the same-day discharge group and 3% of the control group. Among the patients in the control group, 3% suffered from postoperative seizures, whereas no seizures were observed in the case group. These differences were not statistically significant. General anesthesia-related complications were not observed in any of the patients. The authors' findings demonstrate that Enhanced Recovery After Surgery protocols and same-day discharge craniotomy for tumor resection and image-guided biopsy under general anesthesia, when patients are carefully selected, can be safely performed with excellent outcomes in a European clinical setting. The OON program proved to be a viable alternative to conventional hospitalization, showing comparable safety records and offering advantages in terms of patient recovery.

Comparison of Same-Day Discharge with Next-Day Discharge in patients undergoing PCI through Femoral route

Comparison of Same-Day Discharge with Next-Day Discharge in patients undergoing PCI through Femoral route

Enhanced Recovery after Surgery Applied to Pediatric Laparoscopic Cholecystectomy for Simple Cholelithiasis: Feasibility and Teaching Insights.

Same-day discharge after a cholecystectomy is a common practice in the adult population and has been demonstrated as safe and viable for children as well. However, there is a lack of comprehensive teaching models for pediatric cholecystectomy. Drawing inspiration from standardized outpatient procedures, this study aimed to assess the clinical outcomes and feasibility of teaching programs and an Enhanced Recovery After Surgery (ERAS) protocol following ambulatory laparoscopic cholecystectomy in pediatric patients. In 2015, an ERAS pathway for laparoscopic cholecystectomy (LC) was implemented, focusing on admission procedures, surgery timing, anesthetic choices, analgesia, postoperative feeding, mobilization, and pain assessment. Day-case surgery was not applicable for acute cholecystitis, choledochal lithiasis, sickle cell disease, and hereditary spherocytosis cases. The protocol was employed for a group of attending surgeons and fellows, as well as a group of residents under the supervision of experienced surgeons. A retrospective analysis was conducted to evaluate the feasibility and effectiveness of ambulatory cholecystectomy in children and its utilization in training pediatric surgical trainees. Between 2015 and 2020, a total of 33 patients were included from a cohort of 162 children who underwent LC, with 15 children operated on by senior surgeons and 18 by young surgeons. The primary diagnoses were symptomatic gallbladder lithiasis (n = 32) and biliary dyskinesia (n = 1). The median age at the time of surgery was 11.3 years (interquartile range (IQR) 4.9-18), and the median duration of surgery was 54 min (IQR 13-145). One intraoperative complication occurred, involving gallbladder rupture and the dissemination of lithiasis into the peritoneal cavity. Three patients (9%) required an overnight stay, while no postoperative complications or readmissions within 30 days were observed. ERAS was successfully implemented in 30 patients (91%). No significant differences in surgical outcomes were noted between senior and young surgeons. At an average follow-up of 55 months, no long-term sequelae were identified. These findings align with the current trend of increasing use of outpatient laparoscopic cholecystectomy and underscore its feasibility in the pediatric population. The application of a structured ERAS protocol appears viable and practical for training the next generation of pediatric surgeons. Level III.

Assessing Decision Regret in Patients with Same-Day Discharge Pathway After Robot-Assisted Radical Prostatectomy.

Introduction: After the introduction of same-day discharge (SDD) pathways for various surgeries, these pathways have demonstrated comparable complication rates and a reduced overall cost of care. Outpatient robot-assisted radical prostatectomy (RARP) is introduced in high-volume centers; however, patients' perspectives on the SDD RARP protocol are not well understood. Materials and Methods: A questionnaire consisting of 24 questions, including the Likert Decisional Regret Scale, was distributed to patients who underwent RARP at our center. The overall decision regret score was calculated as described in the literature. We used 15 as a cutoff point for differentiating between high- and low-regret rates. Median and interquartile range were determined for non-normally distributed variables, while mean ± standard deviation was calculated for continuous data. Results: Of the 72 patients who completed the questionnaire, 65.7% (n = 44) of patients felt no regret about their decision of choosing the SDD RARP protocol and 90.3% (n = 65) of men stated that they would have made the same decision. At the same time, 97.1% (n = 68) of patients would also recommend this procedure to others. The median decisional regret score of the cohort (n = 67) was 0 (0-10). Fifty-four of 67 (80.6%) patients were in the low-regret score group, while 13 (19.4%) were in the high-regret group. Patients in the high-regret group were more likely to have low household income (<$30,000 a year) and they experienced postoperative pain more frequently compared with patients in the lower regret group (7.7% vs 1.9%, p = 0.626, and 61.5% vs 38.9%, p = 0.212, respectively). Conclusions: Most patients expressed low regret about choosing the SDD pathway for RARP, underscoring the importance of thorough explanation of the procedure and discharge process to enhance patient experience. However, a subset of patients did express regret, possibly due to an interplay of patient- and procedure-related factors.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty

BackgroundA shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution’s most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. MethodsA retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. ResultsOverall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. ConclusionsThe SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. Level of EvidenceIII.