Decreasing carotid endarterectomy length of stay at a university hospital

Discharge on the first postoperative day after elective carotid endarterectomy

BACKGROUND

Medical complications may prolong the hospital stay after elective carotid endarterectomy (CEA). We prospectively assessed the social and medical feasibility and safety of patient discharge on the first postoperative day after elective CEA and unplanned readmissions.

METHODS

Between June 2011 and January 2012, 57 consecutive patients scheduled for elective CEA were enrolled with the aim of discharge on the first postoperative day if there were no medical contraindications and on the condition that the patient should not be left alone during the first day and night at home. CEA was carried out under local or general anesthesia. After discharge, the patients were contacted to ascertain the occurrence of arterial hypertension, cerebral hyperperfusion, focal cerebral ischemia, or hospital readmission.

RESULTS

Sixty-two CEA were carried out in 57 patients (33 men and 24 women ranging in age from 51-89 years). The indications for CEA were: asymptomatic high grade stenosis in 27, hemispheric transient ischemic attack in 12, amaurosis fugax in 6, recovered stroke in 16, and nonlateralizing signs in 1. There were no cases of perioperative stroke or death. Discharge on the first postoperative day was achieved in 45 cases (73%). In 15 cases (24%), discharge was on the second postoperative day because of the absence of a relative (12 cases) or for medical reasons (3 cases). Discharge was on day 3 in 1 case, and on day 10 in another, both for medical reasons. No cases of severe arterial hypertension, stroke, mortality, or readmission for reasons related to the CEA procedure were recorded up to postoperative day 30.

CONCLUSION

In this study, the majority of patients undergoing elective CEA were discharged safely on the first postoperative day. Social reasons, rather than medical reasons, underlied most cases of later discharge. There were no unplanned readmissions for complications of CEA.

15 year experience of carotid endarterectomy at the Royal Brisbane and Women's Hospital: outcomes and changing trends in management

OBJECTIVE

The aim of this study was to review the results of carotid endarterectomy (CEA) at the Royal Brisbane and Women's Hospital (RBWH) to provide a benchmark for comparison with carotid stenting and to document changes in imaging and procedural techniques over time.

METHODS

Analysis of RBWH CEA database from 1992 to 2007.

RESULTS

1313 consecutive patients (average age 69.2 years, 9% 80 years or older, 69% males) underwent carotid endarterectomy at the RBWH between 1992 and May 2007. Indication for surgery was symptomatic disease in 67%. Preoperative investigations included a duplex scan in 97%, an angiogram in 24% and a CT brain in 33%. Angiogram related neurological events occurred in 3.5% of patients (1.6% stroke, 1.9% TIA). There were 7 deaths (0.5%) and 28 strokes (2.1%) for a combined stroke and death rate of 2.4%. The rate of transient ischemic attacks was 1.1%. Gender patch use and trainees operating with the surgeon unscrubbed predicted a higher combined stroke and death rate. Trends over time included: reduction in preoperative angiography from 66% to <5% and increased rate of patching from 39% to approximately 100%.

CONCLUSIONS

Performance of CEA at the RBWH is in keeping with published literature standards. There has been an evolution to surgery performed on the basis of duplex ultrasound alone and an almost universal use of patching.

Carotid endarterectomy then and now: outcome and cost-effectiveness of modern practice

BACKGROUND

During the past decade, our practice of performing carotid endarterectomy (CEA) has changed dramatically, most notably by an abrupt shift from routine to selective preoperative angiography, reliance on defined care plans with full-time nurse practitioner oversight, and increasing reliance on eversion endarterectomy and cervical block anesthesia. This study was designed to determine whether these shifts in policy have been associated with lower costs without sacrificing clinical outcome.

METHODS

All patients undergoing CEA from July 1993 to December 2000 were identified, and inpatient and outpatient charts were reviewed. Cost data were obtained from the central hospital accounting system and converted to 2001 dollars. Thirty-day outcomes and costs were quantified each year and compared between each of 2 temporally well-defined groups: those undergoing "routine" versus "selective" angiography and those cared for before and after defined patient care protocols were instituted.

RESULTS

A total of 1168 CEAs were analyzed. Thirty-day combined stroke and death rate was 3.1%, and no trends or significant differences over time were seen. From 1993 to 2000 the cost of CEA fell from $9302 to $6216 (P<.0002), and length of stay was reduced 1 full day (P=.005). Institution of "selective" angiography was associated with an immediate cost savings of approximately $2000 per case (P<.0001), and nurse practitioner oversight along with institution of defined clinical protocols with a $530 (P<.05) decline in nonoperating room-related costs.

CONCLUSIONS

Changes in policy from routine to selective angiography, reliance on defined postoperative care pathways, eversion endarterectomy, and cervical block anesthesia have been associated with significant cost savings, with no compromise in clinical outcome at our institution.

Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection

BACKGROUND

Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway.

METHODS

One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups.

RESULTS

Mean total length of stay (+/- standard deviation [SD]) was less in the postclinical pathway patients (3.7 +/- 1.5 days) compared to preclinical pathway patients (6.6 +/- 3.3 days) (P <.001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant (P <.001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 +/- 2.8 days and in the prepathway patients was 6.9 +/- 4.1 days (P <.001). The average cost per patient (+/- standard error of the mean), with readmission costs added, was 9310 +/- 5170 US dollars in the prepathway group and 7070 +/- 3670 US dollars in the postpathway group (P =.002).

CONCLUSIONS

The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay.

The Effect of a Critical Pathway on Patients’ Outcomes After Carotid Endarterectomy

• Background In 1996, an integrated plan of care was implemented to improve quality of care for patients undergoing elective carotid endarterectomy. Goals were to reduce length of stay, costs, number of preoperative and intensive care unit admissions, and use of diagnostic procedures yet maintain good outcomes.

• Objectives To determine whether use of the integrated plan of care met the goals.

• Methods Data on financial and process outcomes, use of angiographic diagnostic procedures, and demographics were retrieved from the hospital’s database for all patients who had elective carotid endarterectomy without cerebral infarction.

• Results A total of 783 patients met inclusion criteria: 129 before implementation of the plan of care, 66 during the 6-month transition, and 588 after implementation. Preoperative angiography was done in 32% of patients before implementation, 11% during the transition, and 4% after implementation. Percentages of patients admitted to the intensive care unit were 77% before implementation, 24% during transition, and 9% after implementation. Mean lengths of stay were 2.93 days before implementation, 2.12 days during transition, and 1.68 days after implementation. Costs per case were $7798 before implementation, $5750 during transition, and $5387 after implementation. Analysis of variance revealed significant differences between groups in total length of stay (P=.001), preoperative length of stay (P&lt;.001), and costs (P&lt;.001).

• Conclusion Use of the integrated plan of care reduced length of stay, costs, admissions to intensive care units, and use of cerebral angiography. Use of the plan improved resource utilization while maintaining quality of care.