Significant Decrease In Length Of Stay Research Articles

Olfactory groove meningiomas: supraorbital keyhole versus orbitofrontal, frontotemporal, or bifrontal approaches.

Olfactory groove meningiomas (OGMs) often require surgical removal. The introduction of recent keyhole approaches raises the question of whether these tumors may be better treated through a smaller cranial opening. One such approach, the supraorbital keyhole craniotomy, has never been compared with more traditional open transcranial approaches with regard to outcome. In this study, the authors compared clinical, radiographic, and functional quality of life (QOL) outcomes between the keyhole supraorbital approach (SOA) and traditional transcranial approach (TTA) for OGMs. They sought to examine the potential advantages and disadvantages of open/TTA versus keyhole SOA for the resection of OGMs in a relatively case-matched series of patients. A retrospective, single-institution review of 57 patients undergoing a keyhole SOA or larger traditional transcranial (frontotemporal, pterional, or bifrontal) craniotomy for newly diagnosed OGMs between 2005 and 2023 was performed. Extent of resection, olfaction, length of stay (LOS), radiographic volumetric assessment of postoperative vasogenic and cytotoxic edema, and QOL (using the Anterior Skull Base Questionnaire) were assessed. Thirty-two SOA and 25 TTA patients were included. The mean EOR was not significantly different by approach (TTA: 99.1% vs SOA: 98.4%, p = 0.91). Olfaction was preserved or improved at similar rates (TTA: 47% vs SOA: 43%, p = 0.99). The mean LOS was significantly shorter for SOA patients (4.1 ± 2.8 days) than for TTA patients (9.4 ± 11.2 days) (p = 0.002). The authors found an association between an increase in postoperative FLAIR cerebral edema and TTA (p = 0.031). QOL as assessed by the ASQB at last follow-up did not differ significantly between groups (p = 0.74). The keyhole SOA was associated with a statistically significant decrease in LOS and less postoperative edema relative to traditional open approaches.

Implementation of ESC QI Initiative in Neonatal Unit Setting and Adaptation During the Pandemic.

To improve outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) admitted to NICU by implementing a quality improvement (QI) initiative incorporating "eat, sleep, console" (ESC) as a withdrawal evaluation tool and promotion of nonpharmacological interventions. Secondarily, we evaluated the impact of the coronavirus disease 2019 pandemic on QI initiative and outcomes. We included infants born ≥ 36 weeks gestation and admitted to NICU with a primary diagnosis of NOWS between December 2017 and February 2021. (preintervention; December 2017-January 2019, postintervention; February 2019-February 2021). We compared cumulative dose, duration of opioid treatment, and length of stay (LOS) as our primary outcomes. The average duration of opioid treatment decreased from 18.6 days in the preimplementation cohort (n = 36) to 1.5 days in the first-year postimplementation (n = 44) with a reduction in cumulative opioid dose from 5.8 mg/kg to 0.6 mg/kg and decrease in the proportion of infants treated with opioids from 94.2% to 41.1%. Similarly, the average LOS decreased from 26.6 to 7.6 days. In the second-year postimplementation during the coronavirus disease 2019 pandemic (n = 24), there was an increase in average opioid treatment duration and LOS to 5.1 and 12.3 days respectively, but cumulative opioid dose (0.8 mg/kg) remained significantly lower than the preimplementation cohort. ESC-based quality improvement initiative led to a significant decrease in LOS and opioid pharmacotherapy in infants with NOWS in NICU setting. Despite the impact of the pandemic, some of the gains were sustained with adaptation to ESC QI initiative.

Impact of nutritional compliance within ERAS protocols for hepatopancreatobiliary, radical cystectomy, and head and neck procedures: A case-matched analysis adjusted for major complications

Enhanced recovery after surgery (ERAS®) pathways aim to improve patient outcomes by applying multimodal practices before, during, and after operative procedures. Compared with standard care before ERAS, we investigated whether compliance to ERAS guidelines for nutritional care, preoperative oral carbohydrate loading and postoperative oral nutrition, was associated with a decrease in hospital length of stay (LOS) after pancreaticoduodenectomy, distal pancreatectomy, hepatectomy, radical cystectomy, and head and neck tumor resection with reconstruction. Compliance to ERAS nutrition recommendations was evaluated. Post-ERAS cohort was retrospectively analyzed. Pre-ERAS cohort consisted of case matched patients one year before ERAS: age more than or less than 65 years, body mass index (BMI) more than greater than or less than 30kg/m2, diabetes mellitus, sex, and procedure. Each cohort consisted of 297 patients. Binary linear regressions evaluated the incremental effect of postoperative nutrition timing and preoperative carbohydrate loading on LOS. Multivariate regressions adjusted for postoperative complications. Compliance with preoperative carbohydrate loading for the post-ERAS cohort was 81.7%. Mean hospital LOS was significantly shorter for the post-ERAS cohort compared with pre-ERAS cohort (8.3 vs 10.0 days, p<0.001). By procedure, LOS was significantly shorter for patients undergoing pancreaticoduodenectomy (p=0.003), distal pancreatectomy (p=0.014), and head and neck procedures (p=0.024). Early postoperative oral nutrition was associated with a 3.75-day shorter LOS (p<0.001); no nutrition was associated with a 3.29-day longer LOS (p<0.001). Compliance with ERAS protocols for specific nutritional care practices was associated with a statistically significant decrease in LOS without subsequent increases in 30-day readmission rates and positive financial impact. These findings suggest that ERAS guidelines for perioperative nutrition are a strategic pathway to improved patient recovery and value-based care in surgery.

Outcomes in pediatric total thyroidectomy following implementation of a two-surgeon operative approach.

Pediatric total thyroidectomy is an uncommon procedure. Higher rates of complication are reported for pediatric patients compared to adults which may be secondary to lower case volume. In this study, we examine the effect of a two-surgeon operative approach on outcomes in pediatric total thyroidectomy. A retrospective review of 152 pediatric patients undergoing total thyroidectomy at a single institution was performed. A control group of 89 patients, with one attending surgeon present, was compared to a cohort of 63 pediatric patients who underwent total thyroidectomy with two attendings present. Primary outcomes included rates of permanent hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. The secondary outcomes included postoperative hematoma, length of stay (LOS), LOS greater than 1 day (>1d) secondary to hypocalcemia, and readmissions secondary to hypocalcemia. One RLN injury was documented in each cohort and no postoperative hematomas were documented. Rates of permanent hypoparathyroidism decreased in the two-surgeon cohort (11.48%) when compared to the control group (15.73%) but was not significant. There was a statistically significant decrease in LOS >1d secondary to hypocalcemia in the two-surgeon cohort. LOS >1d attributable to hypocalcemia was seen in 38.2% in the control group versus 15.87% in the 2-surgeon cohort (p=0.003). Implementation of a two-surgeon operative approach was shown to lead to a significant decrease in length of stay >1d attributable to hypocalcemia. However, this change was in the setting of multidisciplinary thyroid team and postoperative protocol implementation, and concentration of surgeons performing the operation. Further studies are needed to investigate the effects of the two-surgeon operative approach further.

P80. Effect of preoperative education on length of stay after elective spinal fusion: a prospective comparative cohort study

<h3>BACKGROUND CONTEXT</h3> Length of stay (LOS) is a major component of hospital cost of inpatient care. Preoperative surgical education has shown to reduce length of stay and overall hospital cost in the orthopedic literature. This same benefit has not been widely studied in patients undergoing spine surgery. <h3>PURPOSE</h3> We sought to demonstrate that preoperative spine surgery education decreases LOS and time-to-first-ambulation after elective spinal fusion. <h3>STUDY DESIGN/SETTING</h3> This is a prospective observational cohort study. We prospectively followed consecutive patients who underwent elective minimally invasive spinal fusion in two hospitals under multiple surgeons from May 2021 through September 2021. The patient population we pulled from was all patients who underwent elective lumbar and cervical fusion including patients with auto or worker's compensation. Patients were excluded if they underwent kyphoplasty or had surgery in the thoracic, C1, pelvis or sacroilliac joint regions. <h3>PATIENT SAMPLE</h3> Four hundred and twelve patients were included. <h3>OUTCOME MEASURES</h3> Our primary outcome for this study was length of stay. Our secondary outcomes were postoperative-day-0 ambulation (POD#0) and first-ambulation distance. <h3>METHODS</h3> Multidisciplinary meetings were held to develop the preoperative spine surgery education material which included a hardcopy booklet, a video embedded in an online quiz and a designated webpage (spineclass.michiganspineandbrainsurgeons.com). This component was part of our institutional Enhanced Recovery After Surgery (ERAS) protocol. During surgical scheduling, patients viewed the video on a tablet. They were given the booklet followed by an email with links to the webpage and pdf booklet. The process measures were compliance with completing the video/quiz and a quiz score with >50% as the passing score. Patient demographics, particularly types of insurance were collected. Univariate analyses were used to compare the compliance groups and multivariable analysis was done to identify factors independently associated with length of stay; p<0.05 was considered significant. <h3>RESULTS</h3> Four hundred and twelve patients were included. Sixty-eight (16.5%) patients viewed the video and completed the online quiz. Average quiz score 79.7 ± 10.8 with a 100% passing rate. There was no significant difference in patient and operative characteristics between the two groups. Compliant patients had a significantly shorter LOS (1.4 ± 1.3, 2.1 ± 2.7, p = 0.45). Preop spine video (B: -0.64, 95% CI: -1.29 - 0, p = 0.050) education was independently associated with a significant decrease in LOS; the converse was true for age (B: 0.05, 95% CI: 0.03 - 0.07, p = <.001). <h3>CONCLUSIONS</h3> We demonstrated that preoperative spine education significantly decreased LOS. Further study to improve compliance is necessary. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Introduction:Previous studies have demonstrated decreased hospital length of stay (LOS) for children undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).Methods:Hospitalization event data from the Kids Inpatient Database were queried for all PSF events for AIS performed in 2009, 2012, and 2016 using diagnosis and surgical codes. Data were subdivided into two groups: pre–enhanced recovery after surgery (ERAS) (2009 and 2012) and post-ERAS (2016). The primary outcome variables were LOS and total treatment charge (adjusted for 2020 inflation). Univariate and multivariate analysis were performed to identify differences in outcome variables.Results:A total of 12,010 unique hospitalization events were identified, 74% female, mean 14.3 years. There was a decrease in LOS (pre-ERAS: 5.4 ± 4.0 versus 4.3 ± 3.2 days, P < 0.0001) with an increase in adjusted total treatment charge (pre-ERAS $193,544.4 ± $108,116.1 versus $200,469.1 ± $110,112.6; P = 0.0013). Pre-ERAS, male sex, smaller hospital, and non-Medicaid insurance were predictive of longer LOS, whereas pre-ERAS, older age, non-White race, male sex, hospital outside the Northeast, and non-Medicaid insurance were predictive of higher treatment costs.Discussion:There continues to be a significant decrease in LOS for PSF hospitalization events for AIS; however, total treatment charges continue to rise. Future research should investigate potential factors influencing total treatment charges after PSF for AIS.

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital.

The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher's exact and Student's t-test. 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.

Application of Enhanced Recovery After Surgery in Patients Undergoing Kidney Transplant: the Belfast Protocol

The aim of this study was to assess the impact of the Belfast Protocol for enhanced recovery after surgery on hospital length of stay (LOS) after kidney transplant. A prospectively collected database was analyzed for all consecutive renal transplant recipients in 2010 and compared with consecutive renal transplant recipients in 2018 before and immediately after the full implementation of the Belfast Protocol. There were 73 renal transplants in 2010 and 115 in 2018. Between 2010 and 2018 there was a significant decrease in LOS from 12 to 7 days (P < .0001). Compared with 2010, in 2018 there was a significant increase in donor age (47 vs 54 years, P < .0001) and kidney transplant from donation after circulatory death donors (0% vs 9%, P < .0001). Although there was no change in the proportion of living donors (59% vs 50%, P=.32), in 2018 there were more blood group incompatible living donors (0% vs 7%, P=.21). Compared with 2010, in 2018 there was a significant increase in recipient age (43 vs 54 years, P=.0002), diabetic nephropathy (5% vs 16%, P=.03), and recipient body mass index >35 kg/m2 (0% vs 9%, P=.02). Implementation of the Belfast Protocol has decreased LOS in renal transplant recipients despite increasingly complex donor and recipient profiles.

235 An Audit of The Post-Op Day One (Pod1) Discharge After Bariatric Surgery – The Effect on Length of Hospital Stay And 30-Day Re-Admission Rate

Abstract Introduction Discharge protocols after bariatric surgery are multi modal. At the Sunderland Royal Hospital, the standard protocol is POD 2 as long as patient satisfies the entire requirements. With the recent drive towards enhanced recovery after surgery, some consultants introduced the POD 1 discharge protocol. Method Using our prospectively maintained bariatric data set POD 1 and POD 2 groups were identified. The length of stay (LOS) and 30-day re- admission was analyzed. Results The average LOS was 2 days for POD 2 group. 19 % of patients were discharged on POD 1, 69% on POD 2 and 6% on POD 3 and 4 each. There were no 30-day re- admissions. In the POD 1 group, the average LOS was 1.4 days. 69% were discharged on POD 1, 25% on POD 2 and 6% on POD 4 with no 30-day re-admission. Conclusions There was significant decrease in LOS with POD 1 discharge with no difference in 30-day re- admission. Therefore, patients could be potentially discharged safely on POD 1 after bariatric surgery.

Colorectal surgical outcomes following implementation of an enhanced recovery after surgery programme in Cape Town

ABSTRACT BACKGROUND: Colorectal surgery is commonly performed for benign and malignant colorectal disease. The aim of this study was to describe length of stay (LOS), complications and its associated factors in patients undergoing elective colorectal surgery following implementation of an enhanced recovery after surgery (ERAS) programme in South Africa (SA METHODS: Socio-demographic, pre- intra- and postoperative clinical details and compliance to the ERAS guidelines were recorded in all patients undergoing colorectal surgery in a private practice in Cape Town, SA. Means and standard deviations or medians and interquartile range (IQR), as appropriate, were used to describe continuous variables and frequencies and percentages for categorical variables. Bivariate and multivariate analyses using linear regression of log transformed LOS and logistic regression for development of complications were performed RESULTS: Between 2015 and 2019, 457 patients had elective colorectal surgical procedures. The median LOS was 5 days (IQR 3-7). Pre- and intraoperative compliance was 92% and 86% respectively. In total, 203 (44%) patients developed 346 complications, of which 61% were minor. On bivariate analysis, increased intraoperative compliance was associated with a significant decrease in LOS (coefficient [ß] = 0.987, 95% confidence interval [CI] 0.984-0.991) and complications (odds ratio [OR] 0.457, 95/5 CI 0.266-0.787). For every additional 30 minutes of theatre time, irrespective of type of procedure, LOS increased by 8% and complications by 12%. On multivariate analysis, laparoscopic compared to open surgery was also associated with a shorter LOS (exp [ß] = 0.667, 95% CI 0.580-0.767 p &lt; 0.001) and reduced complications (OR 0.457, 95% CI 0.266-0.787 CONCLUSION: Our results show that high compliance to the ERAS guidelines is possible in the private sector in SA and that a significant reduction in LOS can be achieved without placing the patient at a higher risk of complications Keywords: colorectal surgery, perioperative care, ERAS, LMIC, surgical checklist

Time Trends in Perioperative Characteristics and Health Outcomes in Hispanic Patients Undergoing Primary Total Knee Arthroplasty.

This study analyzed the yearly trends in procedure utilization, comorbidity profiles, hospital length of stay (LOS), and 30-day outcomes in Hispanic/Latino patients undergoing primary total knee arthroplasty (TKA). Risk stratification for the development of postsurgical adverse events (AEs) was also investigated. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for all Hispanic/Latino patients who underwent primary, elective TKA between 2011 and 2017. Thirty-day outcomes and risk factors were determined using multivariate models that controlled for baseline and perioperative differences. A total of 12,767 Hispanic/Latino patients were identified. Over the study period, the rate of TKA utilization increased by 108%. During the same time, there were significant reductions in the rates of COPD (1.9% vs. 2.9%, p = 0.015), anemia (18.0% vs. 23.5%, p < 0.001), dyspnea (2.9% vs. 4.0%, p = 0.006), and procedure length > 100min (35.2% vs. 39.4%, p < 0.001). Postoperatively, there was a significant decrease in LOS > 2days (41.3% vs. 75.6%, p < 0.001), but there was an increase in the rate of developing 30-day AEs (5.8% vs. 4.7%, p = 0.046). Independent risk factors for 30-day AEs included age > 65years, male sex, chronic steroid use, ASA > 2, diabetes, bleeding disorder, chronic kidney disease, and procedure length > 100min. While the recent trends in procedure utilization, comorbidity profiles, and LOS in Hispanic/Latino patients undergoing primary TKA are reassuring, these have not been accompanied with improved postoperative safety. Patients with bleeding disorders, chronic steroid use, and those admitted from facilities other than home appear to be at highest risk for developing 30-day AEs.

Trends in Microvascular Breast Reconstruction: An Evaluation of 8,561 Cases in the ACS National Surgical Quality Improvement Program Database

Purpose: Since 2012, there has been a 7-fold increase in the number of publications per year pertaining to enhanced recovery after surgery protocols for reconstructive surgery. We hypothesize that for breast reconstruction, the national average length of stay (LOS) has decreased since 2012 without adverse effects on national complication and readmission rates. Methods: We identified female patients who have undergone microvascular breast reconstruction (CPT 19364) from the 2012-2017 ACS National Surgical Quality Improvement Program database. Trends in complication and readmission rates, and LOS were examined over the 6-year period. Multivariate logistic regression models were used to evaluate associations between LOS and readmission rates. Results: 8,561 cases were identified. LOS significantly decreased from 2012-2017 (4.4, 4.2, 4.2, 4.1, 4.0, 3.9 days respectively) (p<0.001). We observed significantly decreased major complication rates from 26.1% to 20.0% (p=0.001). Thirty-day readmission rates remained statistically consistent over the study period from 6.7% to 6.0%. The most common reason for readmission was surgical site infection. For each additional day of LOS, there was 47% increase in odds of complications (OR 1.47, 95% CI: 1.42 to 1.52) and 20% increase in odds of readmissions (OR 1.2, 95% CI: 1.10 to 1.21). Conclusions: Using a national sample from 2012-2017, we observed a significant decrease in LOS for patients undergoing microvascular breast reconstruction. While LOS decreased nationally, we observed a significant decrease in complication rates over the study period but no significant change in readmission rates. Current efforts to reduce LOS are performed safely without increased complication or readmission rates.

Improving Quality With Emergency Department Throughput in a Critical Access Hospital.

The study objective was to determine the impact of specific measures to reduce the length of stay (LOS) in an emergency department (ED) in a critical access hospital (CAH). Despite mandates to reduce bottlenecks by increasing throughput, many EDs are not successful. Strategies available to larger hospitals may not be feasible for resource-limited CAHs. Interventions were implemented to decrease ED LOS in a rural CAH. Through retrospective chart reviews from time periods both preimplementation and postimplementation, the LOS was determined and compared using 2-sample t tests. Significant decreases were found between the groups in mean LOS times, as well as specific time intervals within the overall LOS time for nursing-centric activities and incidence of patients leaving prior to treatment completion. A significant decrease in LOS resulted from numerous actions taken to improve patient flow. Results may be used to enhance patient flow and decrease LOS in other CAHs, improving quality and access to care.

A 2-Year Experience With Enhanced Recovery After Surgery: Evaluation of Compliance and Outcomes in Pancreatic Surgery.

Enhanced Recovery After Surgery (ERAS) programs reduce recovery time, length of stay (LOS), and complications after major surgical procedures. We evaluated our 2-year experience with a newly implemented comprehensive ERAS program at a high-volume center after pancreatic surgery. Outcomes, cost, and compliance metrics were assessed in 215 patients who underwent elective pancreatic surgery (pre-ERAS; n = 99; post-ERAS: n = 116). Mann-Whitney U and χ2 tests were used to evaluate continuous and categorical variables. There were significant decreases in LOS and cost in the post-ERAS cohorts. There were significant increases in compliance with ERAS implementation. Postoperative complication, readmission, and survival rates did not increase. Implementation of ERAS at a large-volume hospital may improve compliance and reduce costs and LOS without increasing adverse outcomes.

Perioperative inhaled corticosteroids treatment is associated with decreased length-of-stay and direct medical costs in high-respiratory-risk surgeries

Aims: To examine the impact of perioperative inhaled corticosteroids (ICS) on length-of-stay (LOS) and costs among patients receiving high-respiratory-risk surgeries.Methods: Adult patients who underwent high-respiratory-risk surgeries in 2015 were identified in the Tianjin Urban Employee Basic Medical Insurance database. Patients were grouped into ICS or non-ICS cohorts according to whether they received ICS during the perioperative period of the index hospitalization. Propensity Score Matching was performed to create matched pairs between two cohorts. The impact of perioperative ICS on LOS and direct medical costs was estimated by negative binomial model and generalized liner model.Results: Eight hundred and twenty-one hospital stays with high-respiratory-risk were selected in the ICS cohort and another 821 stays in the non-ICS cohort were matched. The mean LOS was 13.0 (±0.3) days in the ICS cohort, which was significantly lower than the matched non-ICS cohort. Patients with thorax and ear-nose-throat surgeries had a significant decrease in LOS in the ICS cohort compared to the non-ICS cohort, with a mean decrease of 5.5 and 1.1 days, respectively. In adjusted analyses, perioperative ICS treatment was associated with shorter LOS, lower total, and respiratory-related costs (reductions of 10.1%, 7%, and 5.3%, respectively) after controlling for demographic, clinical, and hospital characteristics.Limitations: Some respiratory risk factors such as living behavior and environment were unable to be captured and respiratory-related costs might be underestimated, limited by claim data. Lastly, caution should be taken when generalizing the results to other populations, as only patients with moderate-to-severe surgeries on the thorax and above were selected in this study.Conclusions: Perioperative ICS treatment was associated with decreased LOS and lower costs for patients undergoing high-respiratory-risk surgeries in China.

Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study

BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have historically been associated with high morbidity given the physiologic insult of an extensive operation. Enhanced Recovery after Surgery (ERAS) pathways have been successful in improving postoperative outcomes for many procedures but have not been well studied in these cases. We examined the feasibility and effect of ERAS pathway implementation for patients undergoing CRS/HIPEC. Materials and methodsPatients with peritoneal carcinomatosis who underwent CRS/HIPEC between October 2015 to September 2018 were identified. Patient characteristics, disease pathology, and perioperative outcome data were obtained. Primary outcomes were hospital length of stay (LOS), 30-d readmissions, renal dysfunction, and complications. ResultsOf the 31 patients who were included, 11 (35.5%) patients underwent CRS/HIPEC prior to the implementation of the ERAS pathway, and 20 (64.5%) patients underwent CRS/HIPEC according to the ERAS guidelines. There were no significant differences in the baseline clinical or pathologic characteristics between groups. There was a significant decrease in LOS with ERAS pathway management from 9 d to 6 d (P = 0.002). No patients from either cohort experienced acute kidney injury. There was no significant difference in 30-d readmission rates or complications. ConclusionsIn this feasibility study, ERAS pathway utilization significantly decreased postoperative LOS for patients undergoing CRS/HIPEC, without evidence of increased complications or readmissions. ERAS programs should be considered for integration into future CRS/HIPEC protocols.

954 Evaluation of Reasons for Admission in Patients With Decompensated Cirrhosis and Their Burden on Health Care Costs and Mortality Over the Years: Nationwide Analysis

INTRODUCTION: Cirrhosis is considered the late stage irreversible sequela of progressive fibrosis and distortion of hepatic architecture. Patients with decompensated cirrhosis have significant morbidity and mortality and may present with signs of upper GI bleeding, ascites, confusion, and kidney injury. The aim of our study was to evaluate and report the trends for the most common causes of decompensation in patients with cirrhosis. METHODS: A retrospective cohort analysis was performed using the Nationwide Inpatient Sample (NIS) from 2007–2014. All patients with a diagnosis of cirrhosis, elective admission, and age greater than 18 years were included in our analysis. We evaluated those who had primary admission diagnosis for ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, esophageal variceal bleeding, and hepatorenal syndrome (HRS). We evaluated the trends of mortality, the length of stay, and cost of hospitalization. RESULTS: Ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, esophageal variceal bleeding, and HRS accounted for 44,614 admissions from 2007–2014 as a primary diagnosis. Mortality for HRS decreased from 36.59% to 24.05% (P &lt; 0.001) from 2007 to 2014, representing average overall mortality of 30.32%. Furthermore, average length of stay (LOS) for spontaneous bacterial peritonitis went from 7.22 days to 6.42 days (P &lt; 0.05). Average LOS went from 9.07 days to 7.88 days (P &lt; 0.05) for hepatic encephalopathy. Average total charges of hospitalization went from $51,665 to $71,779 (P &lt; 0.001) from 2007 to 2014 for hepatic encephalopathy. Average total charges of hospitalization went from $19,692 to $32,336 (P &lt; 0.001) from 2007 to 2014 for ascites. Mortality for bleeding from esophageal varices increased from 5.21% to 6.11% (P &lt; 0.001) from 2007 to 2014, representing average overall mortality of 5.59%. Average total charges of hospitalization went from $34,107 to $51,424 (P &lt; 0.001) from 2007 to 2014 for hepatic encephalopathy. CONCLUSION: Admission for HRS represents approximately 30% overall mortality in patients with decompensated cirrhosis in our study. On the contrary, while the total mean charge for hospitalization increases, spontaneous bacterial peritonitis and hepatic encephalopathy has had significant decrease in LOS from 2007–2014. Clinicians should be vigilant for patients admitted for HRS as it represents high mortality. Further prospective studies are warranted to evaluate the causes for high mortality in decompensated cirrhosis.

MP39: Reducing overcapacity: applying the LEAN model to length of stay in the emergency department

Introduction: Recently there have been many studies performed on the effectiveness of implementing LEAN principals to improve wait times for emergency departments (EDs), but there have been relatively few studies on implementing these concepts on length of stay (LOS) in the ED. This research aims to explore the initial feasibility of applying the LEAN model to length-of-stay metrics in an ED by identifying areas of non-value added time for patients staying in the ED. Methods: In this project we used a sample of 10,000 ED visits at the Health Science Centre in St. John's over a 1-year period and compared patients’ LOS in the ED on four criteria: day of the week, hour of presentation, whether laboratory tests were ordered, and whether diagnostic imaging was ordered. Two sets of analyses were then performed. First a two-sided Wilcoxon rank-sum test was used to evaluate whether ordering either lab tests or diagnostic imaging affected LOS. Second a generalized linear model (GLM) was created using a 10-fold cross-validation with a LASSO operator to analyze the effect size and significance of each of the four criteria on LOS. Additionally, a post-test analysis of the GLM was performed on a second sample of 10,000 ED visits in the same 1-year period to assess its predictive power and infer the degree to which a patient's LOS is determined by the four criteria. Results: For the Wilcoxon rank-sum test there was no significant difference in LOS for patients who were ordered diagnostic imaging compared to those who were not (p = 0.6998) but there was a statistically significant decrease in LOS for patients who were ordered lab tests compared to those who were not (p = 2.696 x 10-10). When assessing the GLM there were two significant takeaways: ordering lab tests reduced LOS (95% CI = 42.953 - 68.173min reduction), and arriving at the ED on Thursday increased LOS significantly (95% CI = 6.846 – 52.002min increase). Conclusion: This preliminary analysis identified several factors that increased patients’ LOS in the ED, which would be suitable for potential LEAN interventions. The increase in LOS for both patients who are not ordered lab tests and who visit the ED on Thursday warrant further investigation to identify causal factors. Finally, while this analysis revealed several actionable criteria for improving ED LOS the relatively low predictive power of the final GLM in the post-test analysis (R2 = 0.00363) indicates there are more criteria that influence LOS for exploration in future analyses.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction.

OBJECTIVEEnhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.METHODSThe authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012-2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016-2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.RESULTSThe pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.CONCLUSIONSThe introduction of the ERAS approach at the authors' institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

Does Rehabilitation before Total Knee Arthroplasty Benefit Postoperative Recovery? A Systematic Review.

Background:Arthritis is the most common form of joint disease. Total knee arthroplasty (TKA) is the most effective surgical intervention for end-stage knee osteoarthritis. The purpose of this study is to access whether patients who participated in preoperative rehabilitation before primary TKA received any postoperative benefit compared to patients who did not participate in preoperative rehabilitation.Materials and Methods:A comprehensive search of Medline, PubMed, Embase, CENTRAL, CINAHL, Ageline, and hand searching references and abstracts was performed. Inclusion criteria included patients undergoing primary and unilateral TKA. Exclusion criteria included patients who have bilateral, unicompartmental, or revision TKA. All studies compared preoperative exercise program versus no preoperative exercise. Outcomes included patients’ function, acute care length of stay (LOS), pain, and stiffness. The Western Ontario and McMaster Universities Osteoarthritis Index and 36-Item Short-Form Health Survey functional scales were used to assess these outcomes. Assessment was performed within 3 months of TKA.Results:Of 1347 articles, 1308 studies were excluded during title and abstract screening. Thirty nine articles underwent full-text screening and were narrowed to five studies matching all criteria. Two studies were combined showing a significant decrease in LOS favoring preoperative exercise (−0.93, 95% confidence interval: −1.29, −0.57). There was a lack of evidence to show any difference regarding self-reported function, stiffness, pain, and physical role.Conclusion:Preoperative exercise program may be beneficial and is associated with a significant decrease in length of hospital stay. No conclusive evidence can be delineated from the literature with respect to clinical outcome measures. Well-designed randomized trials would strengthen this position.