Expedited discharge in uncomplicated acute appendicitis: Decreasing the length of stay while maintaining quality

Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care.

METHODS

MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

RESULTS

After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50).

CONCLUSION

There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.

Novel Quality Improvement Targets to Address Healthcare Encounters After Pediatric Appendectomy

INTRODUCTION

Pediatric appendicitis clinical practice guidelines (CPGs) do not typically address postdischarge healthcare encounters. This study aims to examine common indications for returns to the health system to identify novel quality improvement targets.

METHODS

This retrospective cohort study analyzed patients aged 3 to 18 y undergoing appendectomy at a single institution from July 1, 2019, to July 31, 2020. The primary outcome was physical postdischarge encounters comprising emergency department (ED) visits and hospital readmissions. Indications for each encounter were categorized and stratified by appendicitis type (i.e., simple, gangrenous, or perforated). Multivariable logistic regression models were used to estimate association between appendicitis category and postdischarge encounters.

RESULTS

Of 434 patients, 240 (55.3%) had simple appendicitis, 77 (17.7%) gangrenous, and 117 (29.9%) perforated appendicitis. Overall, 48 patients had at least one instance of an unplanned postdischarge encounter with a total of 56 unplanned ED presentations and 24 readmissions. Perforated patients were significantly more likely to experience postdischarge ED (odds ratio 2.55; 95% confidence interval 1.29-5.02) and readmission encounters (odds ratio 6.63; 95% confidence interval 2.28-19.28). Common indications for ED encounters included abdominal pain (n = 20) with 25.0% readmitted, abdominal pain and gastrointestinal symptoms (e.g., diarrhea, vomiting, distention) (n = 16) with 87.5% readmitted, and incision concerns (n = 6) with 16.7% readmitted. Common indications for readmissions included intraabdominal abscesses (n = 8) and small bowel obstruction (n = 4).

CONCLUSIONS

Assessing indications for postdischarge healthcare encounters enables identification of novel quality improvement targets, including proactively addressing incision concerns and abdominal pain.

Systematic review and meta-analysis of the effects of the perioperative enhanced recovery after surgery concept on the surgical treatment of acute appendicitis in children

BACKGROUND

Enhanced recovery after surgery (ERAS), as a new concept in surgery, has dramatically changed the mode of perioperative treatment for children with acute appendicitis.

METHODS

The retrieval strategy developed by the Cochrane Collaboration was conducted using the CNKI database, Wanfang Medical Network, PubMed, EBSCO, Medline, and Cochrane database by combining subject headings and free words. A review of the randomized controlled trials on the use of the ERAS concept in the perioperative treatment of acute appendicitis in children was conducted between the establishment of the database and May 15, 2021. Keywords included enhanced recovery after surgery, fast track surgery, ERAS, FTS, child, infant, and appendicitis. The quality of the literature was evaluated according to the RevMan 5.3 software provided by the Cochrane Collaboration.

RESULTS

Five randomized controlled trials on ERAS in children with acute appendicitis were finally included. The heterogeneity of postoperative stay time was tested in 4 studies using continuous variables, with Chi-squared test (Chi²) =221.52, degree of freedom (df) =3, I²=99%>50%. An overall analysis using a random effects model showed that the ERAS group was significantly different compared to the control group [Z=5.26; mean difference (MD) =-1.65; 95% CI: -2.27 to -1.03; P<0.00001]. The heterogeneity of the readmission rate was tested in 5 studies using dichotomous variables, with Chi²=5.11, df =3, I²=41%<50%, P=0.91. Overall analysis using a fixed effects model showed no statistically significant difference between the ERAS group and the control group [Z=0.80; odds ratio (OR) =1.16; 95% CI: 0.81 to 1.66; P=0.42]. The heterogeneity of the recurrence rate was tested in 4 studies using dichotomous variables, with Chi²=3.73, df =3, I²=20%<50%, P=0.29. Overall analysis using a fixed effects model showed no statistically significant difference between the ERAS group and the control group (Z=1.14; OR =0.76; 95% CI: 0.47 to 1.22; P=0.26).

DISCUSSION

The results of the meta-analysis confirmed that perioperative application of the ERAS concept in children with acute appendicitis can promote the rehabilitation of children, reduce the postoperative stay time, and reduce the readmission rate and reoperation rate.

Fast-Tracking Patients in an Academic Hospital to Increase Efficiency and Decrease Discharge Delays: A Process Improvement Plan

PURPOSE

The purpose of this quality improvement project was to determine if implementing a Phase II postanesthesia care unit (PACU II) to fast-track patients following surgery in an academic hospital would decrease OR hold times and increase patient flow efficiency.

DESIGN

An observational pre-post design was used to compare PACU bypass rates and recovery times for ambulatory surgery (AS) patients before and after implementation of a patient fast-tracking program.

METHODS

A PACU II was instituted and a fast-tracking program using the White Fast-Track Scoring tool was adopted. Nursing staff as well as anesthesia providers were educated to assess patients using the tool as well as the appropriate patient population to be transferred to the new PACU II.

FINDINGS

Following implementation of the new unit and the fast-tracking program, a PACU bypass rate of 30% was achieved and there was a significant decrease in PACU length of stay for AS patients.

CONCLUSIONS

The results suggest that fast-tracking is a suitable intervention to decrease inefficiencies in an academic setting despite higher acuity patient populations.

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.

Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis

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.

Antibiotics after Simple (Acute) Appendicitis are not Associated with Better Clinical Outcomes: A Post-Hoc Analysis of an EAST Multi-Center Study

Background: The post-operative management of simple (acute) appendicitis differs throughout the United States. Guidelines regarding post-operative antibiotic usage remain unclear, and treatment generally is dictated by surgeon preference. We hypothesize that post-operative antibiotic use for simple appendicitis is not associated with lower post-operative complication rates. Methods: In a post-hoc analysis in a large multi-center observational study, only patients with an intra-operative diagnosis of AAST EGS Grade I were included. Subjects were classified into those receiving post-operative antibiotics (POST) and those given pre-operative antibiotics only (NONE). Clinical outcomes examined were length of stay (LOS), 30-day emergency department (ED) visits and hospital re-admissions, secondary interventions, surgical site infection (SSI), and intra-abdominal abscess (IAA). Results: A total of 2,191 subjects were included, of whom 612 (28%) received post-operative antibiotics. Compared with the NONE group, POST patients were older (age 37 [range 26-50] versus 33 [26-46] years; p < 0.001), weighed more (82 [70-96] versus 79 [68-93] kg (p = 0.038), and had higher white blood cell counts (13.5 ± 4.2 versus 13.1 ± 4.4/10³/mcL (p = 0.046), Alvarado Scores (6 [5-7] versus 6 [5-7]; p < 0.001), and Charlson Comorbidity Indices (median score 0 in both cohorts; p < 0.001). The POST patients had a longer LOS (1 [1-2] versus 1 [1-1] days; p < 0.001). There were no differences in the number who had ED visits within 30 days (9% versus 8%; p = 0.435), hospital re-admission (4% versus 2%; p = 0.165), an index hospitalization SSI (0.2% for both cohorts; p = 0.69), an SSI within 30 days (4% versus 2%; p = 0.165), index hospitalization IAA rate (0.3% versus 0.1%; p = 0.190), 30-day IAA (2% versus 1%; p = 0.71), index hospitalization interventions (0.5% versus 0.1%; p = 0.137) or 30-day secondary interventions (2% versus 1%; p = 0.155). Conclusions: Post-operative antibiotic use after appendectomy for simple appendicitis is not associated with better post-operative clinical outcomes at index hospitalization or at 30 days after discharge.