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Durán Muñoz-Cruzado V, Navarro Morales L, Pareja Ciuró F, Aparicio Sánchez D, Tallón Aguilar L, Padillo-Ruiz J. Safety, Efficacy, and Cost-effectiveness of Outpatient Surgery for Uncomplicated Acute Appendicitis: The PENDI-CSI Randomized Clinical Trial. Ann Surg 2024; 279:24-28. [PMID: 37641981 DOI: 10.1097/sla.0000000000006083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To evaluate the safety, efficacy, and cost-effectiveness of outpatient appendectomy in patients with uncomplicated acute appendicitis. BACKGROUND Given that acute appendicitis is the most common cause of acute abdomen, the introduction of outpatient appendectomy protocols could significantly improve the effectiveness and sustainability of health care systems. METHODS A total of 300 patients were enrolled from October 2018 to June 2021 in the PENDI-CSI randomized clinical trial: 149 were assigned to the outpatient surgery (OPS) group and 151 to the inpatient surgery (IPS) group, followed by 1 month postoperatively. All patients were aged older than 14 years and had uncomplicated acute appendicitis. Exclusion criteria were pregnancy, neoplasms, inflammatory bowel disease, and high anesthetic risk (ASA IV). The OPS group was discharged from the postanesthesia care unit while the IPS group was admitted. RESULTS In total, 128 patients in the OPS group (85.9%) were discharged without admission. Predictors whether patients in the OPS group had to be admitted were aged over 31 years [relative risk (RR): 2.42 (1.04-5.65)], hypertension [RR: 6.21 (3.22-11.97)], anesthetic risk II-III [RR: 2.63 (1.17-5.94)], previous abdominal surgery [RR: 3.34 (1.55-7.20)], postoperative pain with visual analog scale >6 [RR: 4.28 (2.67-6.86)], and postoperative fear [RR: 2.2 (1.04-4.67)]. There were no differences in terms of complications, readmissions, and reinterventions, and the perceived quality was similar in both groups. The outpatient modality produced savings of €1 034.97 per patient ( P < 0.001). CONCLUSIONS Outpatient appendectomy is safe and effective for uncomplicated acute appendicitis. Patient-perceived quality is similar to that of IPS, although it successfully reduces hospital costs compared with inpatient appendectomy.
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Affiliation(s)
- Virgina Durán Muñoz-Cruzado
- Division of General Surgery, Biomedical Institute of Seville (IBIS), Virgen del Rocío University Hospital. Seville, Spain
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Cruz-Centeno N, Stewart S, Marlor DR, Fraser JA, St Peter SD, Oyetunji TA. Satisfaction With Same-Day Discharge After Laparoscopic Appendectomy for Nonperforated Appendicitis. J Surg Res 2023; 288:134-139. [PMID: 36966593 DOI: 10.1016/j.jss.2023.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/31/2023] [Accepted: 02/19/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Same-day discharge (SDD) after laparoscopic appendectomy for acute nonperforated appendicitis is safe, without an increased rate of postoperative complications, emergency department visits, or readmissions. We aimed to evaluate caregiver satisfaction with this protocol. METHODS Patients discharged on the day of laparoscopic appendectomy for nonperforated acute appendicitis were identified between January 2022 and August 2022. Surveys to evaluate satisfaction with the protocol were distributed to the caregivers via email or text message 96 h after discharge. Telephone surveys were conducted if there were no responses to the initial online survey. The surveys assessed comfort with SDD, postoperative pain control adequacy, postoperative provider contact, and overall satisfaction. The protocol focused on avoidance of narcotics in the postoperative period and immediate return to a regular diet. RESULTS A total of 255 cases of nonperforated acute appendicitis underwent SDD. The survey response rate was 50.6% (n = 129). Most respondents were Caucasian (69.0%, n = 89) and male (51.9%, n = 67) with a median age of 12.0 y (IQR 8.9,14.7). The median postoperative length of hospital stay was 3.8 h (interquartile range [IQR] 3.2,4.8). The overall satisfaction rate was 91.5%, with 118 caregivers feeling satisfied with SDD. Most caregivers felt comfortable with the SDD protocol (89.9%, n = 116), with 22.5% (n = 29) calling a medical provider postoperatively. Approximately nine out of 10 caregivers reported that pain was adequately controlled (91.5%, n = 118). In contrast, those that were dissatisfied reported issues with pain control and anxiety with SDD after a surgical procedure. CONCLUSIONS Caregiver satisfaction and comfort with same-day discharge following laparoscopic appendectomy is high with appropriate anticipatory guidance and preoperative education.
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Affiliation(s)
- Nelimar Cruz-Centeno
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Shai Stewart
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Derek R Marlor
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - James A Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri; School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Tolulope A Oyetunji
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri; School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.
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Qurashi FA, Keegan AC, D'Adamo CR, Wolf JH. Post-Operative Day Zero Discharge after Laparoscopic Appendectomy Does Not Worsen High-Yield Outcomes: A NSQIP Database Observational Study. J INVEST SURG 2022; 35:1767-1771. [PMID: 36075582 DOI: 10.1080/08941939.2022.2119493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Background: Post-operative day zero (POD-0) discharge after laparoscopic appendectomy for uncomplicated appendicitis has been studied primarily in single-center or pediatric studies. A larger study from a national sample addressing high-yield outcomes can update and supplement current literature and evaluate early discharge rates.Methods: This is a retrospective, observational National Surgical Quality Improvement (NSQIP) database study of laparoscopic appendectomies for uncomplicated appendicitis performed 2016-2019, with discharge POD-0 or post-operative day one (POD-1). Study outcomes included any or serious complication, unplanned readmission, and unplanned return to operating room (OR). Unadjusted outcomes comparisons were estimated via chi-square tests. Multivariate logistic regression models were constructed to adjust for potential confounders (sex, ethnicity, frailty, ASA score, tobacco use and diabetes).Results: A total of 25,629 patients were included in this analysis. More patients were discharged POD-1 (n = 15,229) than POD-0 (n = 10,440). Rate of any or serious complication was lower in patients discharged POD-0 than POD-1 (any complication: 2.0 vs. 2.8, p = 0.0002, serious complication: 1.4 vs. 2.1, p < 0.0001). Unplanned return to OR and unplanned readmission rates were not different between POD-0 and POD-1 discharged groups (p = 0.9 and p = 0.6, respectively). These findings were robust to adjustment for covariates in logistic regression modeling.Conclusions: This study found that unplanned readmission and other outcomes do not appear to be adversely affected by early discharge after laparoscopic appendectomy for uncomplicated appendicitis, confirming prior evidence on the topic in a large, national sample. It also found that early discharge does not appear to be used in most of these patients.
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Affiliation(s)
- Farheen A Qurashi
- Department of Surgery, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland, USA
| | - Alana C Keegan
- Department of Surgery, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland, USA
| | - Christopher R D'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joshua H Wolf
- Department of Surgery, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland, USA
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Same-Day Discharge after Laparoscopic Appendectomy for Simple Appendicitis in Pediatric Patients—Is It Possible? CHILDREN 2022; 9:children9081220. [PMID: 36010112 PMCID: PMC9406982 DOI: 10.3390/children9081220] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/03/2022] [Accepted: 08/11/2022] [Indexed: 12/02/2022]
Abstract
(1) Background: One-day surgery has been widely adopted for many elective laparoscopic procedures in pediatric patients. Recently, the same protocol has been investigated for some emergency procedures, such as laparoscopic appendectomy. This study aimed to evaluate the safety and effectiveness of discharge from hospital within 24 h in pediatric patients who received laparoscopic appendectomy for uncomplicated acute appendicitis. (2) Methods: From 1 March 2021 to 1 May 2022, a total of 180 pediatric patients who were discharged from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis were included in this prospective single-center study. The primary outcome of this study was the safety of discharge from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis, as well as the parental satisfaction with this protocol. Secondary outcomes included the rate of readmission or unplanned return to the operating room, the complication rate and a cost-effectiveness analysis. For each patient, demographic data, preoperative evaluation (physical examination, laboratory data, imaging), duration of surgery, intraoperative and postoperative complications, length of hospital stay and pain levels, as well as parental satisfaction with this protocol, were recorded. (3) Results: The median age was 11 years (interquartile range (IQR) 10, 14). The majority of the patients (63.8%) were males. The median length of hospital stay after surgery was 15 h (IQR 12, 19). The highest level of satisfaction, at discharge, was recorded in most of the respondents (n = 155, 86.1%), while the remaining 25 (13.9%) expressed moderate levels of satisfaction. The median pain levels according to a visual analogue scale for all postoperative days were low (range 0–4). In four patients (2.2%), unplanned readmission before the seventh postoperative day because of postoperative intraabdominal abscess was recorded. All patients with abscess formation were treated conservatively. The majority of the parents (n = 175; 97.2%) expressed the highest level of satisfaction during the outpatient follow-up examination on the seventh postoperative day. (4) Conclusions: Same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way.
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Roddis B, Ensor N, Williamson S, Funnell H, Murthi S, Pacilli M, Nataraja RM. Criteria-led discharge for simple appendicitis in children: A pilot study. J Paediatr Child Health 2022; 58:1238-1243. [PMID: 35397127 PMCID: PMC9324928 DOI: 10.1111/jpc.15966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 03/01/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Abstract
AIM Criteria-led discharge (CLD) protocols have been suggested to increase efficiency of discharge from hospital following surgical interventions. Our aim was to assess the feasibility, clinical outcomes and parental satisfaction following the introduction of a pilot CLD for simple appendicitis (SA) in children. METHODS A prospective pilot cohort study was conducted including paediatric patients with SA who were managed with CLD and a control group who were managed with standard discharge procedures. A CLD pro forma was developed, standardising care guidelines and clinical criteria indicators to be met for children to be discharged post-operatively. A post-discharge parent survey was also utilised. The primary outcome measure was post-operative length of stay (pLOS), with secondary outcomes of post-operative complication rates and parental satisfaction. RESULTS The control group consisted of 31 patients and CLD group 35 patients. There was no difference in the median pLOS (24 [16.7-44.6] vs. 25.3 [19.1-50.1] h, P = 0.3). Furthermore, there were no significant differences on any of the secondary outcomes. Parental confidence with time of discharge was very high in both control (85.7%) and CLD (88.2%) groups (P = 1.0). CONCLUSION The introduction of CLD is safe and feasible. Whilst this pilot has not demonstrated a reduction in pLOS, our data suggest that it is well accepted by the parents.
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Affiliation(s)
- Bridget Roddis
- Department of Paediatric Surgery and Surgical SimulationMonash Children's HospitalMelbourneVictoriaAustralia
| | - Nicholas Ensor
- Department of Paediatric Surgery and Surgical SimulationMonash Children's HospitalMelbourneVictoriaAustralia
| | - Shona Williamson
- Department of NursingMonash Children's HospitalMelbourneVictoriaAustralia
| | - Hannah Funnell
- Department of NursingMonash Children's HospitalMelbourneVictoriaAustralia
| | - Sangeetha Murthi
- Department of AnaestheticsMonash Children's HospitalMelbourneVictoriaAustralia
| | - Maurizio Pacilli
- Department of Paediatric Surgery and Surgical SimulationMonash Children's HospitalMelbourneVictoriaAustralia,Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia,Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Ramesh M Nataraja
- Department of Paediatric Surgery and Surgical SimulationMonash Children's HospitalMelbourneVictoriaAustralia,Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia,Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
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Buss R, Bodnar CA, Somers KK, Leack KM, Sato TT, Gourlay DM, Van Arendonk KJ. Same-day discharge after appendectomy for uncomplicated appendicitis in children: Potential barriers to increased utilization. Am J Surg 2022; 224:629-634. [DOI: 10.1016/j.amjsurg.2022.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/15/2022] [Accepted: 03/28/2022] [Indexed: 11/01/2022]
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Domene CE, Volpe P, Santana AV. Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1,552 cases operated in 20 years. Rev Col Bras Cir 2022; 49:e20222446. [PMID: 35319561 PMCID: PMC10578856 DOI: 10.1590/0100-6991e-20222446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 12/15/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy. OBJECTIVE to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used. METHODS we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device. RESULTS 1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days. CONCLUSION the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.
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Affiliation(s)
- Carlos Eduardo Domene
- - Centro Integrado de Medicina Avançada e Núcleo Unificado de Tratamento do Obeso, Cirurgia - São Paulo - SP - Brasil
| | - Paula Volpe
- - Centro Integrado de Medicina Avançada e Núcleo Unificado de Tratamento do Obeso, Cirurgia - São Paulo - SP - Brasil
| | - André Valente Santana
- - Centro Integrado de Medicina Avançada e Núcleo Unificado de Tratamento do Obeso, Cirurgia - São Paulo - SP - Brasil
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Zheng Y, Qi S. Feasibility of Same-Day Discharge After Appendectomy in Pediatric Patients: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:944405. [PMID: 35859944 PMCID: PMC9289135 DOI: 10.3389/fped.2022.944405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/13/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To compare the readmission rate, rate of urgent/unplanned visits to emergency, complication rate along with cost of health care among children and adolescents who were discharged the same day following a laparoscopic appendectomy and those who were not discharged on the same day. METHODS A systematic search was performed in the PubMed, Embase, and Scopus databases. Randomized controlled trials and studies, observational in design, were considered for inclusion. The included studies were conducted in children and adolescents with uncomplicated appendicitis undergoing laparoscopic appendectomy and compared outcomes of interest between patients that were discharged the same day (SDD group) following the operation and patients that were discharged within 2 days post-operatively (non-SSD group). Statistical analysis was performed using STATA software. Effect sizes were reported as pooled odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals. RESULTS A total of 13 studies with 32,021 children and adolescents were included. There was no significant difference in the risks of unplanned visit to the emergency department (OR 1.07, 95% CI: 0.78, 1.47), readmission (OR 0.83, 95% CI: 0.66, 1.05), reoperation/re-intervention (OR 1.73, 95% CI: 0.19, 16.2) and complications (OR 0.84, 95% CI: 0.67, 1.06) in both groups of patients. Patients in the SDD group had slightly lower risk of wound infection/complication (OR 0.74, 95% CI: 0.57, 0.96) compared to patients in the non-SDD group. Those with SDD had to incur comparatively lesser hospital expense (in USD) compared to those with no SDD (WMD -2587.4, 95% CI: -4628.3, -546.6). CONCLUSION In children and adolescents with uncomplicated acute appendicitis undergoing laparoscopic appendectomy, same-day discharge is not associated with increased readmission risk, unplanned visits to emergency, and complications. Further, SDD is associated with lower cost of hospital care. Adoption of SDD in this subset of children and adolescents may be encouraged. SYSTEMATIC REVIEW REGISTRATION [www.crd.york.ac.uk/prospero], identifier [CRD420 22320539].
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Affiliation(s)
- Yifei Zheng
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Shiqin Qi
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
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Gee KM, Ngo S, Burkhalter L, Beres AL. Same-day discharge vs. observation after laparoscopic pediatric appendectomy: a prospective cohort study. Transl Gastroenterol Hepatol 2021; 6:45. [PMID: 34423166 DOI: 10.21037/tgh-20-39] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/21/2020] [Indexed: 11/06/2022] Open
Abstract
Background Through 2015, the practice at our university based free-standing children's hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis. Methods Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables. Results Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P<0.0001). Conclusions Same-day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. This study found no differences in outcomes between the timing of discharge, with a significantly lower cost of stay for patients discharged home the same day.
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Affiliation(s)
- Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sandra Ngo
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Alana L Beres
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis, Sacramento, CA, USA
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Ingram MCE, Studer A, Schechter J, Martin SA, Patel M, Roben ECZ, Burjek NE, Birmingham PK, Raval MV. Implementing PDSA Methodology for Pediatric Appendicitis Increases Care Value for a Tertiary Children's Hospital. Pediatr Qual Saf 2021; 6:e442. [PMID: 34345755 PMCID: PMC8322485 DOI: 10.1097/pq9.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children’s referral center. Methods: We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate. Results: LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87–0.94 days) from 1.1 days (IQR 0.97–1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95–6.15) from 5.58 days (IQR 5.16–6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks. Conclusion: Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.
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Affiliation(s)
- Martha-Conley E Ingram
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Abbey Studer
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Jamie Schechter
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Sarah A Martin
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Manisha Patel
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Emily C Z Roben
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nicholas E Burjek
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Patrick K Birmingham
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Mehul V Raval
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
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Lam JY, Beaudry P, Simms BA, Brindle ME. Impact of implementing a fast-track protocol and standardized guideline for the management of pediatric appendicitis. Can J Surg 2021; 64:E364-E370. [PMID: 34223740 PMCID: PMC8410463 DOI: 10.1503/cjs.005420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: In 2017, a provincial guideline was created to fast track and standardize care for pediatric appendicitis in Alberta. We conducted a study to determine the impact of implementation of the guideline at our institution on length of stay (LOS), antibiotic stewardship efforts and costs. Methods: We performed a retrospective review of the charts of all patients younger than 18 years of age who underwent appendectomy at our institution in 2 periods: before guideline implementation (Dec. 1, 2016, to May 31, 2017) and after implementation (Dec. 1, 2017, to May 31, 2018). We compared LOS, duration of antibiotic therapy, 30-day postdischarge complication rates and variable cost between the 2 cohorts. Results: Of the 276 total appendectomy procedures performed, 185 were for simple appendicitis (81 before guideline implementation and 104 after implementation), and 91 were for complicated appendicitis (44 and 47, respectively). The median LOS was shorter in the postimplementation cohort for both simple and complicated appendicitis (15.5 h [interquartile range (IQR) 12–19 h] v. 17.0 h [IQR 13–22 h], p = 0.03; and 3.0 d [IQR 2–4 d] v. 3.0 d [IQR 3–5 d], p = 0.05, respectively). Patients with complicated appendicitis had fewer antibiotic days after guideline implementation; the difference was statistically significant for patients without diffuse peritoneal contamination or abscess formation (p = 0.02). There were no differences between the cohorts with respect to 30-day rates of complications, including emergency department visits, readmission and surgical site infections. After guideline implementation, the average variable cost per patient was reduced by $230, equating to a total average annual cost savings of $75 842 for our institution. Conclusion: The implementation of a provincial guideline aimed at standardizing care in pediatric appendicitis at our institution was associated with shortened LOS, improved antibiotic stewardship efforts and reduced cost of care. Other institutions may replicate our model of a standardized pathway in the management of pediatric appendicitis in an effort to improve the quality of patient care and reduce health care costs.
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Affiliation(s)
- Jennifer Y Lam
- From the Division of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alta. (Lam, Beaudry, Brindle); and Clinical Analytics, Alberta Health Services, Alberta Children's Hospital, Calgary, Alta. (Simms)
| | - Paul Beaudry
- From the Division of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alta. (Lam, Beaudry, Brindle); and Clinical Analytics, Alberta Health Services, Alberta Children's Hospital, Calgary, Alta. (Simms)
| | - Brett A Simms
- From the Division of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alta. (Lam, Beaudry, Brindle); and Clinical Analytics, Alberta Health Services, Alberta Children's Hospital, Calgary, Alta. (Simms)
| | - Mary E Brindle
- From the Division of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alta. (Lam, Beaudry, Brindle); and Clinical Analytics, Alberta Health Services, Alberta Children's Hospital, Calgary, Alta. (Simms)
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Same-day discharge after laparoscopic appendectomy for non-perforated appendicitis is safe and cost effective. Pediatr Surg Int 2021; 37:859-863. [PMID: 33689003 DOI: 10.1007/s00383-021-04880-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
AIM OF THE STUDY To compare the outcomes and hospital charges of patients who underwent laparoscopic appendectomy for non-perforated appendicitis and were discharged home either shortly after the operation after being admitted for overnight observation. METHODS Postoperative (30-day) emergency department (ED) visits, hospital readmissions, and reoperations were compared between patients who were discharged shortly after surgery (same-day discharge [SDD] group) and patients who were discharged after spending one night in the hospital (overnight observation group). STUDY PERIOD July/2015 to June/2019. Patients with perforated appendicitis and/or who spent > 1 night in the hospital were excluded from the study. RESULTS We did 1957 laparoscopic appendectomies within the 4-year study period. After excluding all non-eligible cases, 930 patients were included in the overnight observation group, and 511 in the SDD group. Mean age and mean operative time were similar in both groups: 11.5 (SD 3.6)/11.8 (SD 3.5) years, and 35 (SD 13)/33 (SD 12) minutes, respectively. There were 24 (2.6%) ED visits within the overnight observation group. Sixteen patients (1.7%) were discharged from the ED, and 8 (0.9%) required a re-admission. There were 11 (2.1%; P = 0.61) ED visits within the SDD group. Six patients (1.1%; P = 0.41) were discharged from the ED, and 5 (1%; P = 0.82) required a readmission. Six of the 11 ED visits within the SDD group occurred on the 5th postoperative day or later, whereas five (1%) occurred within the first 3 days post appendectomy. These five patients would have likely benefited from an overnight admission and were erroneously discharged on the same day of the appendectomy. There were no reoperations in the overnight observation group, but there were 3 reoperations in the SDD group (0.6%, P = 0.01). The reasons for the reoperations (two bowel obstructions and one bowel perforation) were in no way related to the time of the original discharge. The mean hospital charges per patient in the SDD group and the overnight observation group were significantly different: $32,450 and $35,420, respectively (> 9% margin, P < 0.01). CONCLUSION Healthy children who undergo laparoscopic appendectomy for non-perforated appendicitis can be discharged home during the same day of the operation after a short period of observation. This approach is safe and does not result in more postoperative ED visits or hospital readmissions. In addition, there is a significant financial benefit when patients are discharged early. LEVEL-OF-EVIDENCE Level III-retrospective comparative treatment study.
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Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols. J Pediatr Surg 2021; 56:663-667. [PMID: 33183744 DOI: 10.1016/j.jpedsurg.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE Therapeutic study; Level 3.
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Cabrera-Rivera PA, Posso Valencia HJ, Dennis-Verano RJ. Beneficios clínicos y de costos de un modelo de estandarización en el manejo de la apendicitis aguda. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introducción. La apendicitis aguda es la patología quirúrgica más frecuente en Colombia y en el mundo, con un riesgo de presentación del 7-8 % en la población general. El tratamiento de elección es la apendicectomía, la cual puede realizarse por vía convencional o por vía laparoscópica. El objetivo de este estudio fue comparar los desenlaces clínicos y costos de un modelo de estandarización en el manejo de la apendicitis aguda versus la no estandarización.
Métodos. Estudio observacional, analítico, para comparar el manejo de atención estandarizado y no estandarizado. Se incluyeron pacientes mayores de 18 años, que ingresaron al servicio de urgencias con diagnóstico de apendicitis aguda en el período de enero de 2016 a diciembre de 2018, y quienes fueron llevados a apendicectomía convencional o laparoscópica en la institución.
Resultados. Se incluyeron 1392 pacientes, 591 que cumplieron los criterios del modelo estandarizado y 801 que cumplieron los criterios del modelo no estandarizado. Al comparar los procesos de estandarización y no estandarización, se encontraron diferencias estadísticamente significativas en los resultados crudos de estancia hospitalaria y costos totales. En los estimativos ajustados por variables de confusión no se encontraron diferencias en los costos totales.
Discusión. El modelo de estandarización demostró una disminución en los días de hospitalización. No encontró diferencias en términos de costos totales.
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Day Care Appendectomy Is Safe in Young Patients with Uncomplicated Early Presentation. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02309-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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Burjonrappa S. Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost. SAGE Open Med 2021; 9:2050312121989627. [PMID: 33552518 PMCID: PMC7841672 DOI: 10.1177/2050312121989627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/30/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose: There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy. Methods: This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared. Results: Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59). Conclusions: Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups. Level of evidence: Level III Type of study: Clinical Study
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Affiliation(s)
- Sathyaprasad Burjonrappa
- Winthrop University Hospitals, Mineola, NY, USA.,Rutgers State University of New Jersey, Bristol Myers Squibb Children's Hospital, New Brunswick, NJ, USA
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Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:1297-1309. [PMID: 33575890 PMCID: PMC8119270 DOI: 10.1007/s00384-021-03872-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients presenting with acute appendicitis are usually hospitalized for a few days for appendectomy and postoperative recovery. Shortening length of stay may reduce costs and improve patient satisfaction. The purpose of this study was to assess the safety of same-day discharge after appendectomy for acute appendicitis. METHODS A systematic review was performed according to PRISMA guidelines. A literature search of EMBASE, Ovid MEDLINE, Web of Science, Cochrane Central, and Google Scholar was conducted from inception to April 14, 2020. Two reviewers independently screened the literature and selected studies that addressed discharge on the same calendar day as the appendectomy. Risk of bias was assessed with the ROBINS-I tool. Main outcomes were hospital readmission, complications, and unplanned hospital visits in the postoperative course. A random effects model was used to pool risk ratios for the main outcomes. RESULTS Of the 1912 articles screened, 17 comparative studies and 8 non-comparative studies met the inclusion criteria. Most only included laparoscopic procedure for uncomplicated appendicitis. Most studies were considered at moderate or serious risk of bias. In meta-analysis, same-day discharge (vs. overnight hospitalization) was not associated with increased rates of readmission, complication, and unplanned hospital visits. Non-comparative studies demonstrated low rates of readmission, complications, and unplanned hospital visits after same-day discharge. CONCLUSION This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients. TRIAL REGISTRATION PROSPERO registration no. CRD42018115948.
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Rossidis AC, Brown EG, Payton KJ, Mattei P. Implementation of an evidence-based protocol after appendectomy reduces unnecessary antibiotics. J Pediatr Surg 2020; 55:2379-2386. [PMID: 32753275 DOI: 10.1016/j.jpedsurg.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Children with acute appendicitis have historically received intravenous antibiotics before and after appendectomy, yet recent literature supports minimizing postoperative antibiotics. In this study, we examined the impact of a standardized protocol that eliminates postoperative antibiotics for nonperforated appendicitis and discontinues antibiotics at discharge for perforated appendicitis. METHODS A retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis between May 2013 and March 2017 was performed. Preprotocol patients (5/1/2013-3/31/2015) were compared to postprotocol patients (5/1/2015-3/31/2017), excluding those who underwent surgery during the month of protocol introduction (4/2015). Primary outcomes were postoperative antibiotic doses for nonperforated cases and antibiotics after discharge for perforated cases. Mann-Whitney and Fisher's exact tests were performed. RESULTS Laparoscopic appendectomy was performed in 748 children before (PRE) and in 814 children after (POST) protocol implementation. Perforation rates were similar (POST 21.5 vs. PRE 21.8%, p=0.90). For nonperforated appendicitis, postoperative antibiotics were reduced (median 0 [IQR 0-0] vs. 3 [0-5] doses, p<0.001), and more patients were discharged less than 24 h after surgery (65.7 vs. 40.9%, p<0.001). Fewer patients with perforated appendicitis underwent PICC placement (8.6 vs. 21.0%, p=0.002), and fewer patients were prescribed antibiotics on discharge (33.7 vs. 89.0%, p<0.001). There were no differences between groups for complication, readmission, or return to ED rates. CONCLUSION For children with acute appendicitis, a standardized protocol can safely reduce unnecessary antibiotics and decrease length of stay. Furthermore, the judicious use of antibiotics does not increase SSI, readmission, or overall complication rates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Avery C Rossidis
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Erin G Brown
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - K Joy Payton
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Peter Mattei
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
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Kim WJ, Jin HY, Lee H, Bae JH, Koh W, Mun JY, Kim HJ, Lee IK, Lee YS, Lee CS. Comparing the Postoperative Outcomes of Single-Incision Laparoscopic Appendectomy and Three Port Appendectomy With Enhanced Recovery After Surgery Protocol for Acute Appendicitis: A Propensity Score Matching Analysis. Ann Coloproctol 2020; 37:232-238. [PMID: 34167189 PMCID: PMC8391045 DOI: 10.3393/ac.2020.09.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/15/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The objective of this study was to compare the perioperative outcomes between single-incision laparoscopic appendectomy (SILA) and 3-port conventional laparoscopic appendectomy (CLA) in enhanced recovery after surgery (ERAS) protocol. METHODS Of 101 laparoscopic appendectomy with ERAS protocol cases for appendicitis from March 2019 to April 2020, 54 patients underwent SILA with multimodal analgesic approach (group 1) while 47 patients received CLA with multimodal analgesic approach (group 2). SILA and CLA were compared with the single institution's ERAS protocol. To adjust for baseline differences and selection bias, operative outcomes and complications were compared after propensity score matching (PSM). RESULTS After 1:1 PSM, well-matched 35 patients in each group were evaluated. Postoperative hospital stays for patients in group 1 (1.2 ± 0.8 vs. 1.6 ± 0.8 days, P = 0.037) were significantly lesser than those for patients in group 2. However, opioid consumption (2.0 mg vs. 1.4 mg, P=0.1) and the postoperative scores of visual analogue scale for pain at 6 hours (2.4±1.9 vs. 2.8 ± 1.4, P = 0.260) and 12 hours (2.4 ± 2.0 vs. 2.9 ± 1.5, P = 0.257) did not show significant difference between the 2 groups. CONCLUSION SILA resulted in shortening the length of hospitalization without increase in complications or readmission rates compared to CLA with ERAS protocol.
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Affiliation(s)
- Won Jong Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeong Yong Jin
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyojin Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hoon Bae
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wooree Koh
- Department of Surgery, Hansol Hospital, Seoul, Korea
| | - Ji Yeon Mun
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Ju Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Ojakäär A, Purdy M, Kechagias A, Järvelin U, Palomäki A. Immediate effects of urgent reorganisation of emergency department-based treatment pathway in nonperforated appendicitis: a retrospective study. BMC Emerg Med 2020; 20:45. [PMID: 32471363 PMCID: PMC7257164 DOI: 10.1186/s12873-020-00339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess, whether this reorganisation was feasible and safe, i.e. did it affect the length of in-hospital stay (LOS) and the 30-day complication rate. METHODS This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-h observation unit of the ED instead of surgical ward. Patients operated during the first 3 months after the reorganisation were compared to those operated during the 3 months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age < 18 years and perforated disease. RESULTS Appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 h for all patients after the reorganisation compared to 24.4 h before the reorganisation (standard error 6.2 h, 95% confidence interval 2.3-15.2 h, p < 0.01). There were no more complications in the group treated postoperatively in the ED. CONCLUSIONS Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED - instead of the surgical ward - occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.
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Affiliation(s)
- Artur Ojakäär
- Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.
| | - Martin Purdy
- Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.,Department of Emergency Medicine, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland
| | - Aristotelis Kechagias
- Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.,Department of Surgery, Rea Hospital, Siggrou Avenue 383, 175 64 P. Faliro, Athens, Greece
| | - Ulla Järvelin
- Department of Emergency Medicine Acuta, Tampere University Hospital, Teiskontie 35, FI-33520, Tampere, Finland
| | - Ari Palomäki
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.,Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
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Guanche Garcell H, Valle Gamboa ME, Guelmes Dominguez AA, Hernández Hernandez E, Bode Sado A, Alfonso Serrano RN. Effect of a quality improvement intervention to reduce the length of stay in appendicitis. J Healthc Qual Res 2019; 34:228-232. [PMID: 31713518 DOI: 10.1016/j.jhqr.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/24/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
AIM Determine the effect of an intervention to reduce the length of stay (LOS) in appendectomies. METHODS A four-quarter quality improvement initiative was developed after approval by the facility Quality Management Department, including educational sessions about the best practices regarding the hospital care for patients with appendicitis and recommendations to limit the LOS for no complicated appendicitis unless associated conditions were present, monitoring of the LOS and feedback to the staff and leaders. RESULTS 692 appendectomies were performed, 365 (52.7%)) of them during the intervention. The mean LOS was 3.94 days with a decreasing trend during the study period. The complicated appendicitis had a mean LOS of 6.42 days (SD, 3.85) during the baseline and 5.27 days (SD 2.50) during the intervention (p=0.03), representing a 17.9% reduction. The not complicated appendicitis during baseline had LOS of 3.82 days (SD 4.17) with a subsequent reduction to 2.95 days (SD 1.53) in the intervention. The total saving bed days during the intervention were 338.04 days, which 254.04 days (75.2%) were in non complicated appendectomies. One patient required readmission during the intervention because of an organ space surgical site infection, with proper recovery after antibiotic treatment. CONCLUSION Our study provides evidence about the possibility to optimize the bed use with a simple educational intervention, and should be considered a step to achieve additional reductions in the hospital stay of patients who undergo laparoscopic appendectomies.
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Affiliation(s)
- H Guanche Garcell
- Infection Control Department, The Cuban Hospital, Hamad Medical Corporation, Qatar.
| | - M E Valle Gamboa
- Surgical Department, The Cuban Hospital, Hamad Medical Corporation, Qatar
| | | | | | - A Bode Sado
- Surgical Department, The Cuban Hospital, Hamad Medical Corporation, Qatar
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22
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Vuagniaux A, Gié O, Butti F, Marques-Vidal PM, Demartines N, Mantziari S. Preoperative Clinical Factors Associated with Short-Stay Laparoscopic Appendectomy. World J Surg 2019; 43:2771-2778. [PMID: 31407096 DOI: 10.1007/s00268-019-05115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Outpatient appendectomy for acute appendicitis is a feasible, yet not widely performed procedure, as there are no universally accepted criteria for patient selection. The aim of this study was to assess preoperative clinical factors associated with successful short-stay appendectomy (SSA) and establish a predictive score to help with patient selection. METHODS All consecutive laparoscopic appendectomies performed in our institution between January 2013 and June 2015 were retrospectively analyzed. Several preoperative clinical and biological variables were compared between patients with SSA, defined as a postoperative stay <24 h, and those needing inpatient care. Logistic regression analysis was used to identify variables independently associated with SSA, and these variables were then used to create a predictive score. RESULTS A total of 578 patients were included, 303 (53%) in the SSA group and 275 (48%) in the long-stay appendectomy (LSA) group. In multivariate analysis, male gender (OR 1.61, 95% CI 1.12-2.31, p = 0.010), ASA class I-II (OR 9.52, 95% CI 1.65-180.69, p = 0.037), absence of generalized guarding (OR 3.55, 95% CI 1.30-11.41, p = 0.019), C-reactive protein <100 mg/dl (OR 3.09, 95% CI 1.81-5.42, p < 0.001) and leukocyte count <20 g/l (OR 2.06, 95% CI 1.02-4.30, p = 0.046) were independently associated with SSA. These five parameters were used to construct a predictive score, whereby ≥17 (range 0-21) was defined as the optimal threshold to predict SSA with a high sensitivity (95.6%) and negative predictive value (82.2%). CONCLUSIONS A purely clinical predictive score based on five widely used preoperative parameters can be used to identify eligible patients for short-stay appendectomy.
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Affiliation(s)
- Aurélie Vuagniaux
- Department of Visceral Surgery and Transplantation, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Olivier Gié
- Department of Visceral Surgery and Transplantation, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Fabio Butti
- Department of Visceral Surgery and Transplantation, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Pedro Manuel Marques-Vidal
- Department of Internal Medicine, University Hospital of Lausanne (CHUV), 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine, Lausanne University UNIL, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery and Transplantation, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine, Lausanne University UNIL, Lausanne, Switzerland.
| | - Styliani Mantziari
- Department of Visceral Surgery and Transplantation, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine, Lausanne University UNIL, Lausanne, Switzerland
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Ngo S, Gee K, Burkhalter L, Beres AL. Parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis. Paediatr Child Health 2019; 24:318-322. [PMID: 31379433 DOI: 10.1093/pch/pxy177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/28/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives Recent studies suggest that same-day discharge is safe for the paediatric population after various laparoscopic procedures. Same-day discharge is increasingly common after laparoscopic surgery for uncomplicated appendicitis although it is not standard practice. This prospective study aims to assess parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis. Methods At our institution, 849 patients with uncomplicated acute appendicitis underwent laparoscopic appendectomy in 2016; of which, 382 were discharged on the same calendar day. Postdischarge surveys assessing parental satisfaction were administered by telephone at the 2-week follow-up. Results Approximately 65% of 185 total parental responses reported initial satisfaction with same-day discharge. About 30% were nervous at that time, and 5% did not feel ready to go home yet. Upon reflection, a higher proportion of parents (81.6%) felt same-day discharge was the appropriate course of action, 11.4% were unsure, and 7.0% would not do it again. Some parents cited concerns regarding pain control and incongruous expectations from conversations with staff or surgical experiences of their own. Conclusions The majority of parents recalled being happy at discharge, with an increase to 82% retrospectively. Only 7% of parents would not elect to go home on the same day again. Opportunities for improvement include a unified plan from all providers with expectations of same-day discharge if appendicitis is intraoperatively confirmed to be uncomplicated and better analgesic instructions at discharge.
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Affiliation(s)
- Sandra Ngo
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Kristin Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | | | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Children's Health, Dallas, Texas, USA
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Wakimoto M, Miller R, Shafy SZ, Tumin D, Veneziano G, Tobias JD. Safety of Same-Day Discharge Compared to Overnight Observation Following Laparoscopic Appendectomy in the Pediatric-Aged Patient: A National Surgical Quality Improvement Program Project. J Laparoendosc Adv Surg Tech A 2019; 29:965-969. [DOI: 10.1089/lap.2019.0046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mayuko Wakimoto
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Shabana Z. Shafy
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Dmitry Tumin
- Department of Pediatrics, East Carolina University School of Medicine, Greenville, North Carolina
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
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Caredda E, Guolo S, Rinaldi S, Brusco C, Raponi M. Outpatient surgery is the solution at hand for reducing costs and hospital stays for pediatric surgery too: a hospital trial. Minerva Pediatr 2019; 72:101-108. [PMID: 31129951 DOI: 10.23736/s0026-4946.19.05426-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Outpatient management has proven to be the most useful method of treatment for various minimally complex surgical specialties compared to day-hospital management or ordinary inpatient processes, a fact confirmed by numerous technical documents and works in the literature. METHODS We analyzed 27,713 surgical interventions carried out in our hospital between 2005 and 2017. This analysis included all interventions for which the indication of the level of care has moved, over the years, to an outpatient setting. We evaluated the direct costs of these services, comparing them by year and by treatment setting. RESULTS From the analysis of costs in general, for the same number of services, a reduction of 56.6% can be seen in the comparison between 2005 and 2017. In addition, the analysis of the length of stay shows an average reduction in the number of days of hospitalization from 2.9 to 1.2 between 2005 and 2017. On the basis of a large quantity of data, our study confirms that outpatient surgery can have a significant impact in reducing costs and days of hospitalization, even in a pediatric setting, demonstrating that it is the best choice in terms of saving resources and, above all, clinical and organizational appropriateness. CONCLUSIONS Outpatient surgery is in fact a valuable solution that provides an advantage for both the patient and his/her family, especially in the pediatric field, for the hospital and more generally for the health system as a whole.
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Affiliation(s)
- Emanuele Caredda
- Bambino Gesù Children's Hospital and Research Institute, Rome, Italy -
| | - Stefano Guolo
- Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Silvia Rinaldi
- Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Carla Brusco
- Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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Pivot D, Hoch G, Astruc K, Lepelletier D, Lefebvre A, Lucet JC, Beaussier M, Philippe HJ, Vons C, Triboulet JP, Grandbastien B, Aho Glélé L. A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence. J Hosp Infect 2019; 101:196-209. [DOI: 10.1016/j.jhin.2018.07.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/24/2018] [Indexed: 01/19/2023]
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Papandria D, Sebastião YV, Deans KJ, Diefenbach KA, Minneci PC. Examining length of stay after commonly performed surgical procedures in ACS NSQIP pediatric. J Surg Res 2018; 231:186-194. [DOI: 10.1016/j.jss.2018.05.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/02/2018] [Accepted: 05/24/2018] [Indexed: 01/19/2023]
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Cheng O, Cheng L, Burjonrappa S. Facilitating factors in same-day discharge after pediatric laparoscopic appendectomy. J Surg Res 2018; 229:145-149. [PMID: 29936981 DOI: 10.1016/j.jss.2018.03.072] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 02/04/2023]
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Same-Day Discharge for Nonperforated Appendicitis in Children: An Updated Institutional Protocol. J Surg Res 2018; 232:346-350. [PMID: 30463740 DOI: 10.1016/j.jss.2018.06.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/13/2018] [Accepted: 06/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The evolving demands of our current health care system for enhanced efficiency and safety while decreasing hospital length of stay has led to our institutional protocol for same-day discharge (SDD) after laparoscopic appendectomy. We have previously demonstrated a 28% rate of SDD in children with nonperforated appendicitis. The purpose of our study is to assess the effectiveness of a mature protocol for SDD by evaluating discharge success, duration of hospital stay, and readmission rates. MATERIALS AND METHODS A retrospective review of prospectively collected data was conducted. All children undergoing a laparoscopic appendectomy for nonperforated appendicitis at Children's Mercy Hospital between December 2015 and July 2017 were included. Patients were classified according to whether they were discharged home the same day as their operation or had an overnight stay. Demographic data, time of day the procedure was completed, postoperative length of stay, and readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA using chi-squared or Fisher exact tests for categorical variables and t-test or Wilcoxon rank sum test for continuous variables. RESULTS A total of 569 children were included, with 87% (n = 495) discharged home the same day as their appendectomy. Of the patients discharged home the same day of surgery, their median length of postoperative stay was 4 h (IQR: 3, 5) compared with 19 h for the patients who stayed overnight (IQR: 15, 25, P < 0.0001). Approximately two-thirds of patients who had their appendectomies after 6 PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% vs. 4%, P = 0.155). CONCLUSIONS After laparoscopic appendectomy in children with nonperforated appendicitis, SDD not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates.
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Abstract
INTRODUCTION For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program. METHODS After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program. RESULTS Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons. CONCLUSION This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.
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Gee K, Ngo S, Burkhalter L, Beres AL. Safety and feasibility of same-day discharge for uncomplicated appendicitis: A prospective cohort study. J Pediatr Surg 2018; 53:988-990. [PMID: 29510871 DOI: 10.1016/j.jpedsurg.2018.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 02/01/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Appendicitis is the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain, and hospital stay after laparoscopic procedures have been significantly reduced. While many laparoscopic procedures are performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis. METHODS After IRB approval, all pediatric patients undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis were eligible for the study. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times, outcomes of complications, readmissions, return to the ED, and nonscheduled clinic visits were collected. RESULTS A total of 1321 appendectomies were performed during the study period, of which 849 were uncomplicated and 382 were discharged same day. There were 2 readmissions, 4 superficial surgical site infections, 10 patients with nausea or vomiting, and 33 patients with pain control issues, 9 of whom presented to the ED. CONCLUSIONS Same day discharge for laparoscopic noncomplicated appendectomy is a safe and feasible alternative to postoperative admission and observation. This has the potential to yield significant healthcare cost savings. LEVEL OF EVIDENCE Level II, Prospective Cohort Study.
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Affiliation(s)
- Kristin Gee
- University of Texas at Southwestern, Dallas, TX, United States
| | - Sandra Ngo
- University of Texas at Southwestern, Dallas, TX, United States
| | - Lorrie Burkhalter
- University of Texas at Southwestern, Dallas, TX, United States; Children's Health, Dallas, TX, United States
| | - Alana L Beres
- University of Texas at Southwestern, Dallas, TX, United States; Children's Health, Dallas, TX, United States.
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Abstract
Ambulatory pediatric surgery has become increasingly common in recent years, with greater numbers of procedures being performed on an outpatient basis. This practice has clear benefits for hospitals and healthcare providers, but patients and families also often prefer outpatient surgery for a variety of reasons. However, maximizing the potential opportunities requires critical attention to patient and procedure selection, as well as anesthetic choice. A subset of outpatient procedures can be performed as single visit procedures, further simplifying the process for families and providers.
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Affiliation(s)
- Andrew B Nordin
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH 43205, United States; State University of New York University at Buffalo, Department of General Surgery, 100 High St, Buffalo, NY 14203, United States
| | - Sohail R Shah
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX 77030, United States; Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza MS390, Houston, TX 77030, United States
| | - Brian D Kenney
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH 43205, United States; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States.
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Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis. J Pediatr Surg 2018; 53:625-628. [PMID: 28693849 DOI: 10.1016/j.jpedsurg.2017.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/26/2017] [Accepted: 06/23/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2012, a same-day discharge protocol following appendectomy for acute appendicitis was initiated. Our objective was to determine the success of the protocol by reviewing the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) outcomes following protocol development. METHODS The 2015 NSQIP-P Participant Use Data File was queried to identify patients with acute appendicitis who underwent appendectomy. Outcomes were compared to institutional outcomes. RESULTS There were 154 institutional patients and 4973 from NSQIP-P centers. Institutional rate of outpatient management was higher compared to NSQIP-P (84% vs 48%, p<0.0001). Surgical length of stay was shorter compared to national rates (0.3±0.7 vs 1.1±1.9days, p<0.0001). There was no significant difference in the incidence of superficial (1.9% vs 1.0%, p=0.2), deep (0.6% vs 0.1%, p=0.17) or organ/space surgical site infections (1.3% vs 0.7%, p=0.31). The incidences of other complications (1.3% vs 0.6%, p=0.26) and 30-day readmissions (3.2% vs 2.6%, p=0.61) were similar. CONCLUSION Outpatient management following appendectomy in children is possible with low morbidity and readmission rates. Comparison with other NSQIP-Pediatric centers suggests an opportunity to generalize this practice with considerable savings to the health care system. LEVEL OF EVIDENCE Prognosis study, level II.
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Cairo SB, Raval MV, Browne M, Meyers H, Rothstein DH. Association of Same-Day Discharge With Hospital Readmission After Appendectomy in Pediatric Patients. JAMA Surg 2018; 152:1106-1112. [PMID: 28678998 DOI: 10.1001/jamasurg.2017.2221] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Appendectomy is the most common abdominal operation performed in pediatric patients in the United States. Studies in adults have suggested that same-day discharge (SDD) after appendectomy is safe and does not result in higher-than-expected hospital readmissions. Objective To evaluate the influence of SDD on 30-day readmission rates following appendectomy for acute appendicitis in pediatric patients. Design, Setting, and Participants This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among pediatric patients who underwent an appendectomy for acute, nonperforated appendicitis. The database provides high-quality surgical outcomes data from more than 80 participating US hospitals, including free-standing pediatric facilities, children's hospitals, specialty centers, children's units within adult hospitals, and general acute care hospitals with a pediatric wing. Patients selected for inclusion (n = 22 771) were between ages 0 and 17 years and underwent appendectomy for uncomplicated appendicitis between January 1, 2012, and December 31, 2015. Patients excluded were those discharged more than 2 days after surgery. Exposures Same-day discharge after appendectomy or discharge 1 or 2 days after surgery. Main Outcomes and Measures The primary outcome was 30-day readmission. Secondary outcomes included surgical-site infections and other wound complications. Results Of the 20 981 patients, 4662 (22.2%) had SDD and 16 319 (77.8%) were discharged within 1 or 2 days after surgery. The patient cohort included 12 860 boys (61.3%) and 8121 girls (38.7%), with a mean (SD) age of 11.0 (3.56) years. There was no difference in the odds of readmission for patients with SDD compared with those discharged within 2 days (adjusted odds ratio [aOR], 0.82; 95% CI, 0.51-1.04; P = .06; readmission rate, 1.89% vs 2.33%). There was no significant difference in reason for readmission on the basis of discharge timing. Likewise, there was no difference in wound complication rate between patients with SDD and those discharged 1 or 2 days after surgery (aOR 0.75; 95% CI, 0.56-1.01; P = .06). Conclusions and Relevance In pediatric patients with acute appendicitis undergoing appendectomy, SDD is not associated with an increase in 30-day hospital readmission rates or wound complications when compared with discharge 1 or 2 days after surgery. Same-day discharge may be an applicable quality metric for the provision of safe and efficient care for pediatric patients with acute, nonperforated appendicitis.
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Affiliation(s)
- Sarah B Cairo
- Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, New York
| | - Mehul V Raval
- Department of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Marybeth Browne
- Department of Pediatric Surgery, Lehigh Valley Children's Hospital, Allentown, Pennsylvania
| | - Holly Meyers
- Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, New York
| | - David H Rothstein
- Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, New York.,Department of Surgery, University at Buffalo, Buffalo, New York
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Gurien LA, Burford JM, Bonasso PC, Dassinger MS. Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis. J Pediatr Surg 2017; 52:1760-1763. [PMID: 28347529 DOI: 10.1016/j.jpedsurg.2017.03.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/10/2017] [Accepted: 03/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy. METHODS A retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for <24-h, and admission for >24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p<0.05 considered significant. RESULTS Of the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted <24-h, and 14 (8%) were admitted >24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission <24-h and >24-h were $1007 and $2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter. CONCLUSION Outpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources. LEVEL OF EVIDENCE III (Treatment: retrospective comparative study).
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Affiliation(s)
- Lori A Gurien
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA; Department of Pediatric Surgery, Arkansas Children's Hospital Research Institute, 13 Children's Way, Little Rock, AR 72202, USA.
| | - Jeffrey M Burford
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA
| | - Patrick C Bonasso
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA; Department of Pediatric Surgery, Arkansas Children's Hospital Research Institute, 13 Children's Way, Little Rock, AR 72202, USA
| | - Melvin S Dassinger
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA
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Yu YR, Smith CM, Ceyanes KK, Naik-Mathuria BJ, Shah SR, Vogel AM, Carberry KE, Nuchtern JG, Lopez ME. A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition. J Pediatr Surg 2017; 53:S0022-3468(17)30633-4. [PMID: 29103787 DOI: 10.1016/j.jpedsurg.2017.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Standardized clinical pathways for simple appendicitis decrease length of stay and result in cost savings. We performed a prospective cohort study to assess a same day discharge (SDD) protocol for children with simple appendicitis. METHODS All children undergoing laparoscopic appendectomy for simple appendicitis after protocol implementation (February 2016 to January 2017) were assessed. Length of stay (LOS), 30-day resource utilization (ED visits and hospital readmissions), patient satisfaction, and hospital accounting costs for SDD were compared to non-SDD patients. RESULTS Of 602 children treated at our institution, 185 (31%) were successfully discharged per protocol. SDD patients had longer median PACU duration (3.0 vs. 1.0h, p<0.001), but postoperative LOS (4.4 vs. 17.4h, p<0.001) and overall LOS (17.1 vs. 31.2h, p<0.001) were significantly shorter. Complication rates (1.6% vs. 3.1%), ED visits (4.3% vs. 6.0%), and readmissions (0.5% vs. 2.4%) were not significantly different for SDD compared to non-SDD patients. However, SDD decreases total cost of an appendectomy episode ($8073 vs $8424, p=0.002), and patients report high satisfaction with their hospital experience (mean 9.4 out of 10). CONCLUSIONS Safe and satisfactory outpatient management of pediatric simple appendicitis is achievable with appropriate patient selection. An SDD protocol can lead to significant generation of value to the healthcare system. LEVEL OF EVIDENCE Prognosis study, Level II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine.
| | - Carolyn M Smith
- Decision Support, Texas Children's Hospital Outcomes and Impact Service, Texas Children's Hospital
| | - Kimberly K Ceyanes
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Bindi J Naik-Mathuria
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Sohail R Shah
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | | | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Monica E Lopez
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
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Frazee R. Can Surgery for Appendicitis Be Performed as an Outpatient Procedure? Adv Surg 2017; 51:101-111. [PMID: 28797332 DOI: 10.1016/j.yasu.2017.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Richard Frazee
- Department of Surgery, Baylor Scott & White Healthcare, Scott & White Clinic, 2401 South 31st Street, Desk 4A, Temple, TX 76508, USA.
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Safety of perioperative ketorolac administration in pediatric appendectomy. J Surg Res 2017; 218:232-236. [PMID: 28985855 DOI: 10.1016/j.jss.2017.05.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/20/2017] [Accepted: 05/24/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Recent studies in adults undergoing gastrointestinal surgeries show an increased rate of complications with the use of ketorolac. This calls into question the safety of ketorolac in certain procedures. We sought to evaluate the impact of perioperative ketorolac administration on outcomes in pediatric appendectomy. METHODS The Pediatric Health Information System database was queried for patients aged 5-17 y with a primary diagnosis of appendicitis and a primary procedure of appendectomy during the period 2010-2014. Patients with procedures suggesting incidental appendectomy, those records with data quality issues, deaths, and extracorporeal membrane oxygenation were excluded. Variables recorded included age, sex, race, ethnicity, discharge year, complex chronic conditions, geographic region, intensive care unit admission, mechanical ventilation, and whether appendicitis was coded as complicated. The exposure variable was ketorolac administration on the day of or day after operation. The primary outcomes of interest were any surgical complications during the initial encounter, postoperative length of stay (LOS), total cost for the initial visit, any readmission to ambulatory, observation, or inpatient status within 30 d, and readmission with a diagnosis of peritoneal abscess or other postoperative infection or with transabdominal drainage performed. RESULTS A total of 78,926 patients were included in the analysis cohort. Mean age was 11.4 y (standard deviation 3.3 y), the majority were males (61%), White (70%), and non-Hispanic (65%). Few had a complex chronic condition (3%) or required mechanical ventilation (2%) or an intensive care unit admission (1%). Patients with complicated appendicitis comprised 28% of the cohort. Most (73%) received ketorolac on postoperative day 0-1; those with complicated appendicitis were more likely to receive ketorolac. In all, 2.6% of the cohort had a surgical complication during the index visit, 4.3% were readmitted within 30 d, and 2% had a postoperative infection or transabdominal drainage (1% in the uncomplicated group and 5% in the complicated group). Median postoperative LOS was 1 d and mean cost was $9811 ± $9509. On bivariate analysis, ketorolac administration was associated with a decrease in same-visit surgical complications (P = 0.004) and cost ($459 decrease, P < 0.001) but was not associated with readmission, postoperative LOS, or postoperative infection. On multivariate analysis, ketorolac administration was associated with a significant decrease in any complication (adjusted odds ratio 0.89, 95% confidence interval 0.80-0.99) and cost (analysis of variance P < 0.001) but was not associated with readmission, postoperative LOS, or postoperative infection. CONCLUSIONS Based on a large, contemporary data set from children's hospitals, ketorolac administration in the immediate postoperative period after appendectomy for appendicitis is common and was not associated with an increase in postoperative LOS, postoperative infection, or any-cause 30-d readmission. Ketorolac was, however, independently associated with a lower overall rate of postoperative complications and cost in this population.
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Bada AM, Ibrahim JA, Safcsak K, Gratzon AC, Smith CP, Cheatham ML. Laparoscopic Appendectomy Protocol Expedites Management of Uncomplicated Acute Appendicitis. Am Surg 2017. [DOI: 10.1177/000313481708300636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bed availability remains a constant struggle for tertiary care centers resulting in the use of management protocols to streamline patient care and reduce length of stay (LOS). A standardized perioperative management protocol for uncomplicated acute appendicitis (UA) was implemented in April 2014 to decrease both CT scan usage and LOS. Patients who underwent laparoscopic appendectomy for UA from April 2012 to May 2013 (PRE group) and April 2014 to May 2015 (POST group) were compared retrospectively. There were no differences in patient demographics or clinical findings between the groups. All patients in the PRE group had a CT scan for the diagnosis of appendicitis, whereas there was a 14 per cent decrease in the POST group (P = 0.002). There was a significant decrease in median LOS between the groups [PRE 1.3 vs POST 0.9 days; (P < 0.001)]. There was no difference in subsequent emergency department visits for complications [3 (4%) vs 4 (4%); P = 1.0] or 30-day readmission rate [1 (1%) vs 5 (5%); P = 0.22] between the groups. A standardized perioperative management protocol for UA patients significantly decreased CT scan utilization and LOS without compromising patient care.
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Affiliation(s)
- Alvaro M. Bada
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Joseph A. Ibrahim
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Karen Safcsak
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Andrew C. Gratzon
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Chadwick P. Smith
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Michael L. Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
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Rosen DR, Inaba K, Oh PJ, Gutierrez AC, Strumwasser AM, Biswas S, Cala M, Ault GT. Outpatient Laparoscopic Appendectomy: Feasible in a Public County Hospital? J Am Coll Surg 2017; 224:S1072-7515(17)30181-3. [PMID: 28433247 DOI: 10.1016/j.jamcollsurg.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, uncomplicated appendicitis. This was a prospective validation study in a large, urban, public safety-net hospital. STUDY DESIGN From 2014 to 2016, all patients undergoing laparoscopic appendectomy for acute, uncomplicated appendicitis were enrolled in a prospective observational trial. Standard baseline perioperative practice (control group) was documented for 1 year. An outpatient appendectomy protocol was then introduced. Inclusion criteria required intraoperative confirmation of uncomplicated appendicitis and strict discharge criteria, including physician assessment before discharge. Data collection then continued for 1 year (outpatient group). The outcomes measures examined included complications, length of stay, nursing transitions, emergency department visits, readmissions, and patient satisfaction. RESULTS The study enrolled 351 patients (178 control, 173 outpatient). Of the 173 candidates for outpatient appendectomy, 113 went home. Reasons for admission included surgeon discretion due to intraoperative findings/medical comorbidities and lack of transportation home. The outpatient group had shorter operative time (69 vs 83 minutes; p < 0.001), longer time in recovery (242 vs 141 minutes; p < 0.001), fewer nursing transitions (4 vs 5; p < 0.001), and shorter postoperative length of stay (9 vs 19 hours; p < 0.001). There was no difference in complications, emergency department visits, or readmissions. In the outpatient group, none of the patients sent home from recovery had postoperative complications or required readmission. Satisfaction surveys revealed no change in satisfaction with either protocol. CONCLUSIONS Outpatient appendectomy is safe in a public hospital and results in shorter hospital length of stay and decreased healthcare costs. Strict criteria for discharge are important to identify patients who should be admitted for observation.
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Affiliation(s)
- David R Rosen
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Kenji Inaba
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Paul J Oh
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Adam C Gutierrez
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Aaron M Strumwasser
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Subarna Biswas
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Melody Cala
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Glenn T Ault
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Yu YR, Abbas PI, Smith CM, Carberry KE, Ren H, Patel B, Nuchtern JG, Lopez ME. Time-driven activity-based costing to identify opportunities for cost reduction in pediatric appendectomy. J Pediatr Surg 2016; 51:1962-1966. [PMID: 27697316 DOI: 10.1016/j.jpedsurg.2016.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE As reimbursement programs shift to value-based payment models emphasizing quality and efficient healthcare delivery, there exists a need to better understand process management to unearth true costs of patient care. We sought to identify cost-reduction opportunities in simple appendicitis management by applying a time-driven activity-based costing (TDABC) methodology to this high-volume surgical condition. METHODS Process maps were created using medical record time stamps. Labor capacity cost rates were calculated using national median physician salaries, weighted nurse-patient ratios, and hospital cost data. Consumable costs for supplies, pharmacy, laboratory, and food were derived from the hospital general ledger. RESULTS Time-driven activity-based costing resulted in precise per-minute calculation of personnel costs. Highest costs were in the operating room ($747.07), hospital floor ($388.20), and emergency department ($296.21). Major contributors to length of stay were emergency department evaluation (270min), operating room availability (395min), and post-operative monitoring (1128min). The TDABC model led to $1712.16 in personnel costs and $1041.23 in consumable costs for a total appendicitis cost of $2753.39. CONCLUSION Inefficiencies in healthcare delivery can be identified through TDABC. Triage-based standing delegation orders, advanced practice providers, and same day discharge protocols are proposed cost-reducing interventions to optimize value-based care for simple appendicitis. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX 77030
| | - Paulette I Abbas
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX 77030
| | - Carolyn M Smith
- Decision Support and Cost Accounting, Texas Children's Hospital, 1919 S. Braeswood, MB6206, Houston, TX 77030
| | - Kathleen E Carberry
- Outcomes and Impact Service, Texas Children's Hospital, 6701 Fannin Dr, Suite 650, Houston, TX 77030
| | - Hui Ren
- Department of Finance, Texas Children's Health Plan, Texas Children's Hospital, 6330 W. Loop South, Suite 800, Bellaire, TX 77401
| | - Binita Patel
- Section of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Dr. Suite A210, Houston, TX 77030
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX 77030
| | - Monica E Lopez
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX 77030.
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Cundy TP, Sierakowski K, Manna A, Cooper CM, Burgoyne LL, Khurana S. Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study. ANZ J Surg 2016; 87:271-276. [PMID: 27599307 DOI: 10.1111/ans.13744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children. METHODS Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach. RESULTS Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057. CONCLUSION Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyra Sierakowski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Alexandra Manna
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Celia M Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Laura L Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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Abstract
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108.
| | - Charles L Snyder
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108
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Appendectomy in the pediatric population—a German nationwide cohort analysis. Langenbecks Arch Surg 2016; 401:651-9. [PMID: 27118213 DOI: 10.1007/s00423-016-1430-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 04/11/2016] [Indexed: 11/26/2022]
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Halter JM, Mallory B, Neilson IR, Langer M. Same-Day Discharge Following Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis as a Measure of Quality in the Pediatric Population. J Laparoendosc Adv Surg Tech A 2016; 26:309-13. [PMID: 27058614 DOI: 10.1089/lap.2016.0093] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Jeffrey M. Halter
- Department of Surgery, Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
| | - Baird Mallory
- Department of Surgery, Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
| | - Ian R. Neilson
- Department of Surgery, Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
| | - Monica Langer
- Department of Surgery, Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
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Oyetunji TA, Gonzalez DO, Aguayo P, Nwomeh BC. Variability in same-day discharge for pediatric appendicitis. J Surg Res 2015; 199:159-63. [DOI: 10.1016/j.jss.2015.04.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 04/07/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
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47
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Dalton BG, Gonzalez KW, Knott EM, St. Peter SD, Aguayo P. Same day discharge after laparoscopic cholecystectomy in children. J Surg Res 2015; 195:418-21. [DOI: 10.1016/j.jss.2015.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/24/2015] [Accepted: 02/12/2015] [Indexed: 01/11/2023]
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DOMENE CE, VOLPE P, HEITOR FA. Three port laparoscopic appendectomy technique with low cost and aesthetic advantage. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2014; 27 Suppl 1:73-6. [PMID: 25409972 PMCID: PMC4743525 DOI: 10.1590/s0102-6720201400s100018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 08/14/2014] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Despite dating more than 30 years after the first laparoscopic appendectomy, ileocecal appendix resection is still performed by laparotomy in more than 90% of cases, in our country. AIM To describe a technique for laparoscopic removal of the ileocecal appendix with three portals, at low cost and very good aesthetic appearance. TECHNIQUE Three incisions, one umbilical and two suprapubic are made; permanent material used comprises: grasping forceps, hook, scissors, needle holders, three metal trocars and four other usual instruments, and a single strand of cotton. There is no need to use of operative extractors bags, clips, endoloops, staples or bipolar or harmonic energy instruments. Allows triangulation and instrumentation in the conventional manner. CONCLUSION The proposed technique is safe and reproducible, easily teachable, at very low cost and can be applied in general hospitals with conventional laparoscopic equipment.
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Affiliation(s)
- Carlos Eduardo DOMENE
- From the Centro Integrado de Medicina Avançada e Núcleo Unificado de
Tratamento do Obeso (Integrated Center for Advanced Medicine and Unified Center for
Treatment of the Obese), São Paulo, SP, Brazil
| | - Paula VOLPE
- From the Centro Integrado de Medicina Avançada e Núcleo Unificado de
Tratamento do Obeso (Integrated Center for Advanced Medicine and Unified Center for
Treatment of the Obese), São Paulo, SP, Brazil
| | - Frederico Almeida HEITOR
- From the Centro Integrado de Medicina Avançada e Núcleo Unificado de
Tratamento do Obeso (Integrated Center for Advanced Medicine and Unified Center for
Treatment of the Obese), São Paulo, SP, Brazil
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