Same-day Discharge Research Articles

Clinical and Economic Outcomes of a Systematic Same-Day Discharge Program After Pulmonary Vein Isolation: Comparison between Cryoballoon versus Radiofrequency Ablation.

Same-day discharge (SDD) is feasible after pulmonary vein isolation (PVI). We aim to compare prospectively cryoballoon (CRYO) versus radiofrequency (RF) ablation in a systematic SDD program. We prospectively analyzed the 617 scheduled PVI performed consecutively at our institution (n = 377 CRYO, n = 240 RF) from April 1, 2019 to December 31, 2022 within a systematic program of SDD. The feasibility of SDD, the 10-day incidence of urgent/unplanned medical care after discharge (UUC-10), and the cost per procedure due to hospital resource use were studied. The 100 procedures performed during the previous year, in which patients were systematically hospitalized, were used as a control group. SDD was achieved in 585/617 (95%) procedures, with a significant trend towards a higher monthly SDD rate from 2019 to 2022 (p = 0.03). The frequency of SDD was similar in CRYO (356/377; 94%) vs. RF (229/240; 95%). After SDD, the UUC-10 was 66/585 (11.3%), being similar for CRYO (41/356; 11.5%) and RF (25/229; 10.9%); p = 0.8 (log-rank test). Of these, 10 patients were re-hospitalized, with an identical rate in CRYO- (6/356; 1.7%) and RF-treated (4/229; 1.7%) patients and owing to similar causes (4 hematomas, 4 pericarditis, and 2 symptomatic sinus node dysfunction). SDD was associated with an average savings per procedure of 63% (p < 0.001), but no differences were found between the CRYO and RF (p = 0.8). In a systematic SDD program, feasibility (95%, increasing over time), safety (11% UUC-10, 1.7% re-hospitalizations), and savings (63% per procedure) were similar for CRYO and RF ablation.

Routine use of intraoperative nerve monitoring is associated with a reduced risk of vocal cord dysfunction after thyroid cancer surgery

BackgroundThe aim of this study was to investigate the associations between individual surgeon’s intraoperative nerve monitoring (IONM) practice and factors associated with vocal cord (VC) dysfunction in patients with thyroid cancer undergoing thyroidectomy.MethodsUsing Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) 2014-21 data, multivariable logistic regression analyses investigated variables associated with short- and long-term VC-dysfunction, associations of routine use of IONM with postoperative outcomes, and patient characteristics associated with IONM use.ResultsAmong 5,446 patients (76.7% female, mean age 49 years), 68.5% had surgery by surgeons using IONM in ≥ 90% of cases (63% of surgeons, n = 73). Post-operative VC-dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short-term and 2.7% in the long-term. When surgeons routinely used IONM, the incidence of VC-dysfunction was 2.4% in the short-term and 2.2% in the long-term, compared to 4.4% and 3.7%, respectively, when surgeons did not routinely use IONM (p < 0.01). After adjustment, routine use of IONM was independently associated with reduced risk of short- (OR 0.48, p < 0.01) and long-term (OR 0.52, p < 0.01) VC-dysfunction, a lower risk of postoperative hypoparathyroidism in the short- (OR 0.67, p < 0.01) and long-term (OR 0.54, p < 0.01), and higher likelihood of same-day discharge (OR 2.03, p < 0.01). Extrathyroidal tumor extension and N1-stage were factors associated with postoperative VC-dysfunction in the short- (OR 3.12, p < 0.01; OR 1.92, p = 0.01, respectively) and long-term (OR 3.11, p < 0.01; OR 2.32, p < 0.01, respectively).ConclusionRoutine use of IONM was independently associated with a lower risk of endocrine surgery-specific complications and greater likelihood of same-day discharge.

Ablation of atrial fibrillation in an ambulatory outpatient setting.

The safety of atrial fibrillation (AF) ablation in an ambulatory outpatient center has not previously been reported. The aim of this study is to report the feasibility and safety of AF ablation in an ambulatory setting. We identified all AF ablations performed at the Alaska Heart and Vascular Institute's ambulatory center since program initiation to current day using billing records. Procedural complications, postoperative utilization of hospital services, and emergency room (ER) utilization were captured by chart review. A total of 476 patients underwent pulmonary vein isolation in the ambulatory setting over a 6.3-year period. Patients' average age was 58 ± 9.3 years, body mass index was 32.9 kg/m2, and the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score was 1.7. For 85%, this was the first AF ablation, and 55% had paroxysmal AF. Cryoablation was used in 85%. A combined primary safety outcome capturing potentially unstable perioperative safety events occurred in 1.5% of patients, all of whom were stabilized prior to hospital transfer. A total of 1.5% of patients required same-day hospital services, with another 1.5% returning to the ER within 24 hours. A total of 96% of patients did not require hospital services within 24 hours of ablation. The 30-day ER utilization was 13.7%, similar to published data of same-day discharge of AF ablation done in the hospital setting. There were no emergent cardiac surgical interventions and no mortality events. Catheter ablation for AF in the ambulatory setting is both feasible and safe in this large single-center experience. More studies are needed to confirm this next frontier in catheter ablation for AF.

Effectiveness and Safety of Same-Day Discharge After Left Atrial Appendage Closure Using Moderate Conscious Sedation: One-Year Follow-Up Outcomes

Effectiveness and Safety of Same-Day Discharge After Left Atrial Appendage Closure Using Moderate Conscious Sedation: One-Year Follow-Up Outcomes

Pivotal Protocol for Same-Day Discharge Using Cardiac Magnetic Resonance Pre-Procedural Planning for Left Atrial Appendage Closure

Pivotal Protocol for Same-Day Discharge Using Cardiac Magnetic Resonance Pre-Procedural Planning for Left Atrial Appendage Closure

Enhanced Recovery After Surgery (ERAS®) Society Guidelines for Gynecologic Oncology: Addressing Implementation Challenges - 2023 Update

ABSTRACT Implementation of the Enhanced Recovery after Surgery (ERAS) Society Guidelines in 2016 has resulted in an approximate decrease in hospital length of stay (LOS), reduction in complications and readmission, and cost saving. Recent publications however have demonstrated that barriers and gaps in understanding may result in many ERAS recommendations being poorly adhered to in gynecologic oncology patients. The aims of this second update to the ERAS Society Guidelines for gynecologic oncology is to summarize and update the evidence investigating specific implementation challenges to increase ERAS uptake and improve clinical outcomes for patients. A literature search was conducted for topics specified to 9 ERAS implementation challenges identified: perioperative oral intake safety, preoperative medication importance, penicillin allergies, intraoperative analgesia, how to manage urinary drainage, venous thromboembolism prophylaxis, postoperative opioid prescription practices, same-day discharge programs, and how can I overcome barriers to ERAS implementation. The quality of evidence and recommendations was evaluated, and recommendations graded as strong or weak based on quality, balance between desirable and undesirable effects on holistic clinical outcomes, and on values and preferences of practitioners. Regarding perioperative oral intake safety, patients should be encouraged to consume clear liquids in 2 hours before surgery and preoperative carbohydrate loading improves satisfaction and comfort. Optimal preoperative medications include nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids. Patients with penicillin allergies should receive standard surgical antibiotic prophylaxis. For intraoperative analgesia, wound infiltration with local anesthetic and TAP block are preferred over thoracic epidural analgesia. Indwelling bladder catheters should be removed as early as possible in the postoperative period such as on the day of surgery for minimally invasive procedures and no later than postoperative day 1 for laparotomy. Patients at increased risk of venous thromboembolism should receive dual prophylaxis with compression and medications, and extended chemoprophylaxis should be prescribed to those with high-risk criteria or after laparotomy. Multimodal opioid-reduction is critical for all patients, and decreased postdischarge opioid proscribing is improved with a team approach and does not affect pain control or patient satisfaction. Patient controlled analgesia is a last resort for those requiring repeated treatment with intravenous opioids. Multidisciplinary same-day discharge programs should be considered in minimally invasive surgeries, and implementation requires a multidisciplinary team approach with patient education, case selection, and ERAS principles. Overcoming barriers to ERAS principles is more successful with changes at the management level and education. Communication of the economic benefits of ERAS to administrators may be a strong incentive to garner support. Although the evidence level varied between moderate and strong for each of these recommendations, the recommendation grade for each was strong. This updated ERAS guideline focuses on addressing implementation challenges and controversial aspects of ERAS defined by a stakeholder clinician group and offers suggestions based on objective data for overcoming these barriers.

Feasibility of Same-Day Discharge Approach After Transcatheter Mitral Valve Repair Procedures: One-Year Follow-Up Outcomes

Feasibility of Same-Day Discharge Approach After Transcatheter Mitral Valve Repair Procedures: One-Year Follow-Up Outcomes

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands

To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP). A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed. A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P<.01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P=.10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P=.51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P<.01). Median foley catheter duration was longer in SP-RASP (6 vs 1day, P<.01) and trial of void was successful at first attempt in >94% (P=.68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P<.01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings. SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

Patient, operative and pain management factors influencing inpatient compared with surgical day care mastectomy procedures at a community hospital.

The COVID-19 pandemic highlighted the importance of maximizing same-day discharge after surgery to mitigate potential patient harms associated with inpatient admission and conserve valuable hospital resources. Adoption of same-day discharge after breast surgery, particularly mastectomy, has been slow despite recent research suggesting the physical and psychological benefits of same-day discharge after surgery. We sought to identify factors associated with inpatient compared with surgical day care mastectomy procedures at a community hospital in Vernon, British Columbia. We conducted a retrospective chart review of all patients who underwent a total mastectomy without reconstruction at Vernon Jubilee Hospital, a 196-bed community hospital, between April 2016 and March 2019. Patient characteristics, operative variables and pain management were compared between inpatient and surgical day care mastectomy procedures. We also compared 7-day readmission, reoperation and complications. A total of 187 mastectomy patients were analyzed with 72 (38.5%) surgical day care procedures. Factors associated with inpatient procedures included longer operative time (66.1 min v. 53.5 min, p = 0.001), bilateral mastectomy (91% v. 9%, p = 0.01) and suspected or confirmed obstructive sleep apnea (32% v. 17%, p = 0.04). Preoperative acetaminophen (83% v. 17%, p < 0.001), multilevel intercostal block (83% v. 17%, p < 0.001) and a prescription for acetaminophen plus tramadol (58% v. 42%, p < 0.001) were associated with day care surgeries. There were no significant differences between the inpatient and surgical day care groups with respect to 7-day readmission, reoperation or postoperative complications. We found no significant differences in surgical outcomes between inpatients and those with same-day discharge after mastectomy procedures. These findings add to the growing body of evidence that surgical day care mastectomy procedures are safe in the community setting.

Ambulatory Orbital Fracture Repair: An Analysis of ER Visits After Surgery From a Multistate Study.

To determine the 30-day postoperative emergency room (ER) visit rate following ambulatory orbital fracture repair with same-day discharge, and the causes and risk factors associated with ER visit. Database study. State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) for California, New York, and Florida for 2011. We identified orbital fracture repair procedures among adults from the SASD, which was linked to the SEDD to identify the incidence and causes of ER visits within 30 days. Univariate and multivariable logistic regression models were used to determine the factors associated with ER visit. Among 762 patients, the 30-day postoperative ER visit rate was 4.5%. Most ER visits (58.9%) occurred during the first week after surgery. The most common reasons for ER visits were related to pain, swelling, headache, dizziness, and fatigue (29.4%), followed by ophthalmologic etiologies including visual disturbances and infection of the eye (14.7%). There was no case of retrobulbar hematoma. In the multivariate analysis, patients living in Florida were at a significantly higher risk for ER visit compared to those in California (odds ratio: 4.48 [1.43-14.10], p = .010). Ambulatory orbital fracture repair appears to be safe. Common reasons for ER visit included pain, swelling, and ophthalmic symptoms. An increased risk for ER visit was seen with certain geographic regions but not with medical comorbidities or concurrent facial fractures or procedures.

Initiation of a Comprehensive Early Discharge Program at a Veterans Affairs Hospital.

Early discharge protocols have become a major surgical paradigm, but this protocol is not routinely used in the Veteran Affairs (VA) system. The primary objective was to demonstrate the feasibility of a comprehensive joint program (CJP) protocol, including same-day discharge, at a VA hospital. Secondary objectives are to determine whether an increase in postoperative complications, increased readmissions, and increased ER visits compared with previous management protocols occur. A retrospective review of patients undergoing primary total joint arthroplasty conducted before the initiation of CJP was compared with patients undergoing primary total joint arthroplasty conducted after the initiation of CJP. The two cohorts were subdivided further into total knee arthroplasty (TKA) and total hip arthroplasty (THA). Patients' demographics, medical comorbidities, discharge disposition, length of stay (LOS), surgery information, 30-day and 90-day postoperative complications, surgical site infections, and emergency room visits were collected and assessed with paired t -tests. A total of 200 control cases (101 TKA, 99 THA) were compared with 260 cases (165 TKA, 95 THA) in the CJP group. The mean LOS reduced from 4.38 days in the control group to 0.75 days in the CJP group ( P < 0.001), with 890 total inpatient days in the control group compared with just 200 total inpatient days with the CJP group. A total of 92 patients (34.5%) in the CJP group were discharged the same day compared with 0 in the control group ( P < 0.001). In the control group, 47.8% were discharged to rehabilitation centers compared with only 4.5% in the CJP group ( P < 0.001). The 30-day complication rate was reduced with CJP (5.6% vs. 10.3% control) ( P = 0.028). ER visits did not significantly change (8.9% control vs. 9.3% CJP; P = 0.77). Overall LOS and complication rates were reduced with the CJP, exemplifying the viability of such a protocol in the VA system. In addition, we demonstrated no increased risks accompanied with early discharge to home. This initiative can be used to reduce healthcare dollars in VA healthcare system nationally.

Current Oncology Reports: Enhanced Recovery in Gynecologic Oncology Surgery-State of the Science.

The purpose of this review is to describe the state of the science of enhanced recovery after surgery (ERAS) in gynecologic oncology. Over the last 5years, there is mounting evidence supporting ERAS in gynecologic oncology surgery. Despite this, surveys have found suboptimal uptake of ERAS, and stakeholders have highlighted the difficulty of ERAS implementation as a major barrier. To address this, the core components required for a successful ERAS implementation program (protocol, ERAS team, audit system) are reviewed. ERAS developments specific to gynecologic oncology are also discussed, including same-day discharge initiatives for minimally invasive surgery, implications of telemedicine, and methods to increase uptake of ERAS in low- and middle-income countries. ERAS is a surgical quality improvement program with strong evidence supporting its effectiveness in gynecologic oncology. Efforts are required to address ERAS implementation barriers to increase uptake globally, especially in low-income settings.

Analysis of Sociodemographic Factors Affecting Ambulatory Surgical Center Discharge Patterns for Endometrial Cancer Hysterectomies

Investigate outcomes for patients undergoing minimally invasive hysterectomies (MIHs) performed for endometrial cancer at ambulatory surgery centers (ASCs). Our study aimed to explore the feasibility and discharge outcomes for MIHs for endometrial cancer in an ASC setting by using same-day discharge data. The prevalence of MIH for endometrial cancer between 2016 and 2019 was estimated from the Nationwide Ambulatory Surgery Sample. Patients who underwent MIHs for endometrial cancer at an ASC were included. N/A MEASUREMENTS MAIN RESULTS: Weighted estimates of prevalence and association between discharge status and sociodemographic factors were explored. Same-day discharge was defined as discharge on the day of surgery, and delayed discharge was defined as discharge after the day of surgery. An estimated 95041 MIHs for endometrial cancer were performed at ASCs between 2016 and 2019. Notably, 91.9% (n=87372) resulted in same-day discharge, 1.2% (n=1121) had delayed discharge, and 6.9% (n=6548) had missing discharge information; 78.7% procedures (n=68812) were performed at public hospitals. The proportion of delayed discharges were lower in private, not-for profit ASCs (0.8%, p=.03) than public hospitals. Patients who had delayed discharges on average were older (69.7 vs 62.4 years, p <.001), more likely to have comorbid conditions including diabetes (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.25-1.75) and overweight or obese body mass indices (aOR 1.18, 95% CI 1.01-1.39), and more likely to have public insurance (aOR 1.78, 95% CI 1.40-2.25). MIHs for endometrial cancer are feasible in an ASC. Optimal candidates for receipt of MIHs for endometrial cancer at an ASC are patients who are younger and have less comorbidities, lower body mass index, and private insurance.

Outcomes of same-day discharge following percutaneous coronary intervention in a rural population.

Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is safe, yet the nationwide rate of SDD remains low. The impact that residing in a rural area has on the safety of SDD is unknown. To investigate the safety of SDD compared to next-day discharge (NDD) among PCI patients living in a largely rural area. There were 3502 outpatient elective PCIs at a tertiary care center between January 1, 2011 and December 31, 2017. Data from the National Cardiovascular Data Registry CathPCI Registry® and the electronic medical records were obtained for patient demographics, procedural characteristics, and procedural outcomes. Data from the initial PCI in each 365-day period were included in the analysis for each patient. Rural-Urban Commuting Areacodes 4-10 were used to define rural status. A total of 2099 (59.9%) PCIs met the inclusion criteria (63% rural). The overall rate of SDD increased over time (4.7% in 2011 to 39.6% in 2017) as radial access increased (14.2% in 2011 to 59.9% in 2017). In this population, a total of 329 PCIs had SDD (15.7%; median (interquartile range) age 66.0 (14.0) years, 20.1% female, 52.3% rural status). Compared to NDD, SDD patients had less hyperlipidemia, atrial fibrillation, congestive heart failure, history of coronary artery bypass graft, and more radial access. SDD was noninferior to NDD for 30-day readmission but had a decreased 1-year (adjusted odds ratio [aOR]: 0.20, 95% confidence interval [CI]: 0.05-0.81, p = 0.024) and 5-year (aOR: 0.43, 95% CI: 0.28-0.66, p < 0.001) all-cause mortality compared to NDD. Rural status did not predict outcomes. SDD in patients in rural areas does not have a significantly higher rate of 30-day readmission. SDD patients had lower odds of 1- and 5-year mortality when compared to NDD. Future studies prospectively evaluating the safety of SDD in this population are warranted.

Performing urological inpatient procedures as same-day procedures during the COVID pandemic: A retrospective feasibility study.

In line with Canadian provincial directives due to the COVID-19 pandemic, certain elective urological surgical cases that are normally performed as inpatient procedures, were performed as same-day discharge procedures to reduce hospitalization and the usage of scarce healthcare resources. Since the pandemic, we began performing laser enucleation of the prostate (LEP), robotic-assisted radical prostatectomy (RARP), and percutaneous nephrolithotomy (PCNL) as outpatient surgeries. This was supported by recent evidence demonstrating the safety and feasibility of performing these minimally invasive surgeries as same-day procedures. As such, we sought to retrospectively evaluate the clinical outcomes and safety during the COVID-19 era at our institution for same-day discharge LEP, RARP, and PCNL procedures. All patients operated for LEP, RARP, or PCNL between May 2020 and March 2022 at two academic institutions were included. Surgeries were classified as planned same-day discharge or inpatient surgery. Same-day discharge patients were compared to inpatients for each procedure type. This comparison assessed the occurrence of same-day failure, postoperative complications, and re-admission rates at 30 days. This study was approved by the scientific ethics committee of the Centre de Recherche de l'Université de Montréal (CRCHUM). A total of 413 subjects were included in this study. Among LEP patients (n=169), 104 (62%) were identified as same-day procedures and 65 (38%) were inpatient. Among RARP patients (n=194), 46 (24%) were identified as same-day procedures and 148 (76%) inpatient. Among PCNL patients (n=50), 38 (76%) were identified as same-day procedures and 12 (24%) were inpatient. Of the patients who underwent planned same-day LEP, RARP, and PCNL, 77.9%, 73.9%, and 71.1% were successfully discharged home, respectively. Patients who underwent LEP as inpatient had a higher incidence of overall postoperative complications compared to same-day LEP (23.1% vs. 8.7%, p=0.017). The rates of 30-day emergency department (ED) visits and hospital re-admission were similar between inpatient and same-day LEP (9.2% vs. 3.8%, p=0.27; and 4.6% vs. 1.0%, p=0.32, respectively). Inpatient RARP, however, was associated with more 30-day ED visits compared to same-day procedures (17.4% vs. 4.1%, p<0.01). No statistically significant differences were found for postoperative complications (15.2% vs. 6.1%, p=0.097) and re-admission rates (1.4% vs. 4.3%, p=0.51). There were no significant differences on overall postoperative complications, 30-day ED visits, and readmission rates in inpatient vs. same-day PCNL. Our results suggest that same-day discharge for LEP, RARP, and PCNL is safe and feasible in select patients with an acceptable complication rate. These results should be validated in a larger, prospective clinical trial comparing same-day and inpatient procedures.

Having Outpatient Major Elective (HOME) Robotic Colon Resection Protocol: A Safe Approach to Ambulatory Colon Resection.

Within the past decade, colorectal surgery length of stay (LOS) has decreased from an average of 5-6 days to 2-3 days. However, elective colon resections have yet to become a common procedure with the potential for same-day discharge. During the COVID pandemic, hospital capacity was exceptionally strained and colon resections were delayed due to the lack of inpatient beds available. We sought to create a protocolized ERAS (enhanced recovery after surgery) pathway that would allow for safe and feasible ambulatory colon resections as well as decreasing overall hospital inpatient burden. Between November 2020 and March 2022, 15 patients were offered same-day discharges under the HOME protocol. Of the 15 patients, 11 patients agreed to be discharged home the day of surgery and followed prospectively for 30 days. All procedures were performed robotically. Patients were selected based on level of preoperative health (ASA class 1 and 2), low-risk for loss to follow-up, ability for close family supervision for 3 days postoperatively, and type of procedure (partial colectomy). Close follow-up was achieved with daily telephonic or televideo visits for 3 days post-operatively, as well as a 2-week outpatient clinic follow-up. A total of 11 patient underwent same-day surgery utilizing the protocol, 5 females and 6 males, between the ages of 34 and 62. All patients were ASA class 2. Indications for colon resection were cecal volvulus (1), recurrent sigmmoid diverticulitis (9), and Crohn's disease (1). Primary outcome was readmission rates within the 30-days. There were no readmissions or complications during the perioperative 30-day period. There was one emergency department return for pain who was not admitted. Average operative time was 132.1 minutes. Using a novel enhanced recovery protocol, we demonstrated the feasibility and safety of ambulatory partial colectomy in a highly select small subset of patients.

Enhanced Risk Stratification for Short-Term Complications Following Vertebral Augmentation for Osteoporotic Vertebral Compression Fractures.

For patients with back pain from osteoporotic vertebral compression fractures (VCFs), vertebral augmentation remains the most utilized surgical intervention. Previous studies report 30-day readmission and mortality rates of up to 10% and 2%, respectively. These studies, however, have included patients with pathologic fractures and combined patients in different admission settings. We undertook the current study to address such shortcomings, which make risk stratification and appropriate counseling difficult. Four consecutive years of the National Surgical Quality Improvement Program database were queried. Patients who underwent vertebral augmentation for osteoporotic VCFs were divided into 3 groups: (1) outpatient group (defined as patients with same-day discharge), (2) inpatient group (defined as those who were admitted postoperatively), and (3) preprocedure hospitalized group (defined as those who were already inpatient or were at acute/intermediate care facilities and transferred). Postoperative 30-day complications and readmission rates were compared between different groups and examined using multivariate analyses. A total of 1023 patients underwent outpatient surgery; 503 were admitted on the day of surgery; and 149 patients were already in-hospital or were transferred from other facility. Mortality rates were 0.68%, 0.60%, and 2.68%, and readmission rates were 6.26%, 6.76%, and 12.8%, for outpatient, inpatient, and preprocedure hospitalization cohorts, respectively. Multivariate analyses identified preprocedure hospitalization as an independent risk factor for urinary tract infection (UTI; OR = 3.98, 95% CI = 1.41-11.20, P = 0.028), pneumonia (OR = 19.69, 95% CI = 3.81-101.65, P < 0.001), readmission (OR = 1.86, 95% CI = 1.06-3.26, P = 0.032), and mortality (OR = 4.49, 95% CI = 1.22-16.53, P = 0.024). Our findings suggest that published rates of complications and mortality are substantially impacted by the cohort of patients who are already hospitalized or transferred from other facilities. Such patients are at a higher risk of UTI, pneumonia, readmission, and mortality. Conversely, we show that a relatively healthy patient being offered outpatient same-day augmentation has a readmission risk 40% lower and a mortality risk 3 times lower than previously reported.

Enhanced recovery and same-day discharge hospital stay: speed versus safety?

Lay Summary Same-day ambulatory major surgery is evolving, but requires more study regarding patient selection and safety.

Transitioning from intrathecal bupivacaine to mepivacaine for same-day discharge total joint arthroplasty: a quality improvement study

IntroductionSame-day discharge total knee and hip arthroplasty is becoming more common. Anesthetic approaches that optimize readiness for discharge are important. Based on an institutional change from low-dose bupivacaine to mepivacaine,...

Optimizing primary total shoulder arthroplasty in the COVID era: shorter length of stay with no increase in the complication profile

BackgroundThe novel coronavirus (COVID-19) pandemic had significant impact on surgical volume of total shoulder arthroplasty (TSA) with a 55% decline during the second quarter of 2020. As restrictions eased, TSA volume recovered back to its prepandemic baseline by Q3/Q4. The purpose of this study was (1) to compare the postoperative length of stay (LOS), discharge disposition, complications, emergency department (ED) utilization, hospital readmissions, and reoperations within 90 days following TSA before and during the pandemic era and (2) to evaluate surgical trends of TSA induced by the pressures of the global pandemic. MethodsAll patients undergoing either primary anatomic or reverse TSA between January 2018 and December 2021 were included. Procedures performed before March 11, 2020 were considered the “pre-COVID” cohort while those after were considered the “COVID era” cohort. The outcome measures included postoperative LOS, discharge disposition, complications, ED utilization, hospital readmissions, and reoperations within 90 days following TSA. P < .05 was considered statistically significant. ResultsThere were 227 and 96 patients in the pre-COVID and COVID era groups, respectively. There were no differences in age (P = .6), gender (P = .06), body mass index (P = .33), Elixhauser Comorbidity Index (P = .8), TSA indication (P = .65), or arthroplasty type (P = .61) between pre-COVID and COVID cohorts. During the pandemic, there was a significant increase in same-day discharge TSA (49% vs. 28.2%, P < .001), and 37.9% of pre-COVID patients had a LOS between 1 and 2 days as compared to 18.8% in the COVID era group. Ultimately, there were no differences in any complications or frequency of 30- or 90-day ED encounters, readmissions, or reoperations between pre-COVID and COVID era cohorts (P > .05 for all). ConclusionPrimary TSA during the pandemic was associated with more frequent same-day discharge without increased postoperative complications, ED encounters, readmissions, or reoperations at up to 90-days postoperatively. Our results suggest that primary TSA, a procedure historically associated with an inpatient stay, can safely be performed expeditiously in an outpatient setting without increasing patient morbidity or mortality.