Same day admission for elective cardiac surgery: how to improve outcome with satisfaction and decrease expenses

Day Admission Surgery Program in a Prospective Payment System: What Are the Financial Incentives?

Background

Day admission surgery (DAS) is meant to provide a better in-hospital experience for patients and to save costs by reducing the length of stay. However, in a prospective payment system, it may also reduce the reimbursement amount, leading to unintended incentives for hospitals.

Methods

Over a 4-month period in 2021 and based on predefined clinical and logistic criteria, patients from different surgical sub-specialties were identified to follow the institutional DAS program. Revenue-analysis was performed, considering the Swiss diagnosis-related group (SwissDRG) prospective payment policy. Revenue with DAS program was compared to revenue if patients were admitted the day prior surgery (No DAS) using nonparametric pooled bootstrap t-test. All other costs considered identical, an estimation of the average cost spared due to the avoidance of pre-operative hospitalization in the DAS setting was carried out using a micro-costing approach.

Results

Overall, 105 inpatients underwent DAS over the study period, totaling a revenue of CHF 1 209 840. Among them, 25 patients (24%) were low outliers due to the day spared from the DAS program and triggering a mean (SD) financial discount of Swiss Francs (CHF) 4192 (2835), yielding a total amount of CHF 105 435. DAS revealed a mean revenue of CHF 7320 (656), compared to CHF 11 510 (1108) if patients were admitted the day before surgery (No DAS, P = .007).

Conclusion

In a PPS, anticipation of financial penalties when implementing a DAS for all-comers is key to prevent an imbalance of the hospital equation if no financial criteria are used to select eligible patients. Promptly revising workflow to maintain constant fixed costs for a greater number of patients may be a valuable hedging strategy.

Effect of the Kanghuier Transparent Hydrocolloid Dressing in Preventing Central Venous Catheter Infection and Phlebitis after Cardiac Surgery

Background

As cardiac surgery is complicated, time-consuming, and traumatic, it may cause great damage to the patient's body. Therefore, postoperative indwelling venous catheters are required for hemodynamic monitoring and rapid fluid replenishment. Intravenous catheterization infection can easily lead to phlebitis, which not only affects the success of the operation and patient recovery but may also lead to death in severe cases. Good perioperative care is key to reducing postoperative infection in patients, and the choice of dressings for patients with catheterization plays an important role in reducing catheter infection.

Objective

The Kanghuier transparent hydrocolloid dressing is known to effectively prevent and treat wound infections. This study is aimed at exploring whether it can reduce the incidence of postoperative catheter infection and phlebitis in patients undergoing cardiac surgery.

Methods

A total of 196 patients undergoing cardiac surgery in the Department of Cardiothoracic Surgery of Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University) from January 2020 to June 2020 were selected. Among them, 98 patients receiving Kanghuier transparent dressing intervention were selected as group A, and the remaining 98 patients receiving traditional sterile gauze intervention were selected as group B. The incidence of infection and related complications, phlebitis, inflammatory factors, pain at the infusion site, nursing comfort and satisfaction, and quality of life were analyzed and compared between the two groups.

Results

It was found that compared with group B, the postoperative central venous catheter infection rate and the incidence of phlebitis were significantly lower in group A. In addition, the inflammatory response of patients in group A was better relieved. Moreover, the nursing comfort and satisfaction and the quality of life of patients in group A were significantly improved.

Conclusion

This study suggests that the Kanghuier transparent hydrocolloid dressing is effective in the prevention and treatment of central venous catheter infection and phlebitis in patients after heart surgery.

A Novel Video-Based Patient Education Program to Reduce Penile Prosthetic Surgery Cancellations

Penile prosthetic surgery is an effective treatment for men with erectile dysfunction. Cancellation of surgery is disruptive and costly to patients, physicians, and the healthcare system. This pilot study sought to analyze surgery cancellations and implement a video-based patient education program to decrease surgery noncompletion.

Baseline penile prosthetic surgery completion, rescheduling, and cancellation rates among consecutively scheduled surgeries were determined using a national cohort. Selected prosthetic surgeons then implemented Vidscrip, a video-based patient education program. Prerecorded videos were delivered via text message 14 days, 7 days, and 1 day preoperatively, as well as 1 day postoperatively. Subsequent analysis determined noncompletion rates, reasons for noncompletion, surgeon volume, and video utilization.

Two-hundred twenty-six surgeries were scheduled in the baseline cohort; 141 were completed, and 85 were rescheduled or canceled. Among the intervention cohort, 290 patients completed, 7 rescheduled, and 37 canceled surgery. After program implementation, the surgery noncompletion rate was reduced compared to baseline (13.2% vs. 37.6%, p < .05), corresponding to a number needed to treat of 4.1. When stratified by surgeon volume, there was no difference in noncompletion rate (>20 cases vs. ≤20 cases: 8.20% vs. 32.0%, p = .35). Video utilization was widely variable among practices (median viewing time 58.6 min, IQR 5.09–113).

Penile prosthetic surgery is frequently rescheduled or canceled. Implementing a video-based patient education program reduces surgery noncompletion, improving efficiency and quality of care. Wider implementation is needed to validate these findings, while cost-effectiveness analyses may further support their broad adoption.

Using Lean Six Sigma to improve rates of day of surgery admission in a national thoracic surgery department

Objective

The aim of this study is to improve rates of day of surgery admission (DOSA) for all suitable elective thoracic surgery patients.

Design

Lean Six Sigma (LSS) methods were used to enable improvements to both the operational process and the organizational working of the department over a period of 19 months.

Setting

A national thoracic surgery department in a large teaching hospital in Ireland.

Participants

Thoracic surgery staff, patients and quality improvement staff at the hospital.

Intervention(s)

LSS methods were employed to identify and remove the non-value-add in the patient’s journey and achieve higher levels of DOSA. A pre-surgery checklist and Thoracic Planning Meeting were introduced to support a multidisciplinary approach to enhanced recovery after surgery (ERAS), reduce rework, improve list efficiency and optimize bed management.

Main Outcome Measure(s)

To achieve DOSA for all suitable elective thoracic surgery patients in line with the National Key Performance Indicator of 75%. A secondary outcome would be to further decrease overall length of stay by 1 day.

Results

Over a 19 month period, DOSA has increased from 10 to 75%. Duplication of preoperative tests reduced from 83 to <2%. Staff and patient surveys show increased satisfaction and improved understanding of ERAS.

Conclusions

Using LSS methods to improve both operational process efficiency and organizational clinical processes led to the successful achievement of increasing rates of DOSA in line with national targets.