Time is money: quantifying savings in outpatient appendectomy

Effects of clinical nursing pathway on surgical site wound infection in patients undergoing acute appendicitis surgery: A meta-analysis

This study aimed to explore the impact of clinical nursing pathway applied to acute appendicitis surgery on patients' postoperative wound infections and complications. A computerised search of PubMed, Cochrane Library, Web of Science, EMBASE, Wanfang, Chinese Biomedical Literature Database and China National Knowledge Infrastructure was conducted and supplemented by a manual search, from database inception to October 2023, to collect randomised controlled trials (RCTs) on the application of clinical nursing pathways to acute appendicitis surgery. Literature screening, data extraction and quality assessment of the included literature were carried out independently by two researchers. RevMan 5.4 software was applied for data analysis. Twenty-one RCTs with a total of 2408 patients were finally included. The analysis revealed the implementation of clinical nursing pathway could effectively reduce the incidence of wound infection (OR = 0.26, 95% CI: 0.15-0.46, p < 0.001) and postoperative complications (OR = 0.20, 95% CI: 0.15-0.27, p < 0.001), as well as shorten the hospital length of stay (MD = -3.26, 95% CI: -3.74 to -2.79, p < 0.001) and accelerated the time to first ventilations (MD = -14.85, 95% CI: -21.56 to -8.13, p < 0.001), as well as significantly improved patient satisfaction (OR = 5.52, 95% CI: 3.52-8.65, p < 0.001) in patients undergoing surgery for acute appendicitis. The application of clinical nursing pathway in acute appendicitis surgery can significantly reduce postoperative wound infection and complications, and at the same time can shorten the hospital length of stay as well as improve the satisfaction of patients.

Reducing Post-Operative Hospital Length of Stay following Uncomplicated Appendectomy in Pediatric Patients: A Prospective Clinical Study

An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children's hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3-16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.

Routine post-operative labs and healthcare system burden in acute appendicitis

BACKGROUND

Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management.

METHODS

A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected.

RESULTS

A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient.

CONCLUSIONS

In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.

Beneficios clínicos y de costos de un modelo de estandarización en el manejo de la apendicitis aguda

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.

Fast track pathway provides safe, value based care on busy acute care surgery service

BACKGROUND

Fast track (FT) pathways have been adopted across a multitude of elective surgeries but have been slow to be adopted into the acute care surgery realm. We hypothesized that an FT pathway for acute cholecystitis patients would decrease patient length of stay and resource utilization.

METHODS

All patients at two hospitals, one with an FT pathway and one with a traditional pathway, who underwent an urgent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019, and October 31, 2019, were queried using CPT codes. Exclusion criteria were conversion to open or partial cholecystectomy. Retrospective chart review was used to gather demographics, operative, hospital course, and outcomes. Time to operating room, hospital length of stay, and resource utilization were the primary outcomes.

RESULTS

There was a total of 479 urgent laparoscopic cholecystectomies performed, 430 (89.8%) were performed under the FT pathway. The median (interquartile range [IQR]) time to the operating room was not different: 14.1 hours (IQR, 8.3-29.0 hours) for FT and 18.5 hours (IQR, 11.9-25.9 hours) for traditional (p = 0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours; IQR, 14.2-40.4 hours vs. 38.5 hours; IQR, 28.3-56.3 hours; p < 0.001). Under the FT pathway, 33.0% of patients were admitted to the hospital and 75.6% were discharged from the postanesthesia care unit, compared with 91.8% and 12.2% on the traditional pathway (both p < 0.001). There were 59.6% of the FT patients that received a phone call follow up, as opposed to 100% of the traditional patients having clinic follow up (p < 0.001). The emergency department bounce back rate, readmission rates, and complication rates were similar (p > 0.2 for all). On multivariate analysis, having a FT pathway was an independent predictor of discharge within 24 hours of surgical consultation (odds ratio, 7.65; 95% confidence interval< 2.90-20.15; p < 0.001).

CONCLUSION

Use of a FT program for patients with acute cholecystitis has a significant positive impact on resource utilization without compromise of clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Risk Factors for Readmission After Short-Hospital-Stay Laparoscopic Appendectomy

BACKGROUND

Single-day discharge is a common practice among patients undergoing laparoscopic appendectomy (LA). We aimed to determine risk factors associated with readmission in patients with short hospital stay after LA.

METHODS

We performed a retrospective analysis of all patients who underwent LA during the period 2006-2019. Patients with length of hospital stay shorter than 24 h were included. Demographics, operative variables, and postoperative outcomes were analyzed. Multivariable logistic regression was performed to determine risk factors for readmission.

RESULTS

A total of 2009 LA were performed during the study period; 1506 (75%) patients had short hospital stay and were included in the analysis. Median age was 31 (14-85) years, and 720 (48%) were female. Mild peritonitis was diagnosed in 423 (28%) patients, and 121 (8%) had gangrenous/perforated appendicitis. Mean surgical time was 51(14-180) min. Conversion rate was 0.4%. There were 143 (9%) postoperative complications, including 29 (1.9%) patients with postoperative intra-abdominal abscess. Nine patients (0.6%) underwent reoperation, and only 26 (1.7%) patients were readmitted. The mean time to hospital readmission was 6 (1-14) days. Although age >50 years, obesity, mild peritonitis, and complicated appendicitis were more frequent among patients readmitted, only age >50 years (OR 3.54 95% CI 1.51-8.30) and mild peritonitis (OR 6.16 95% CI 1.80-34.93) were found as independent risk factors for readmission.

CONCLUSION

Most patients undergoing LA can be safely discharged within 24 h of admission. Patients over 50 years old and/or with localized peritonitis have significantly higher risk of readmission and therefore may need a closer postoperative follow-up.