Effect of Surgery Start Time on Day of Discharge in Anterior Cervical Discectomy and Fusion Patients

Late-week Multilevel Anterior Cervical Discectomy and Fusion Associated With Increased Length of Stay

STUDY DESIGN

Retrospective analysis of clinical data from a single institution.

OBJECTIVE

To assess the day of surgery during the week as a possible predictor of length of stay (LOS) following anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Surgeries later in the week may result in longer LOS and higher costs for joint arthroplasty, yet this is unclear following spine surgery. Procedures performed later in the week may lead to weekend admissions when there are limited services that may contribute to an extended LOS. We attempt to identify associations between day of surgery and LOS, readmission, and complications following single- and multilevel ACDF.

MATERIALS AND METHODS

Patients at a single institution undergoing ACDF by 7 primary surgeons in both orthopedic and neurosurgery spine departments between 2015 and 2019 were retrospectively reviewed. Patients were stratified by surgery day at either the beginning (Monday/Tuesday) or end (Thursday/Friday) of the week and by single- or multilevel ACDF. Surgery for trauma, infections, adjacent level disease, or revision were excluded. Patient demographics, Charlson Comorbidity Index (CCI), LOS, postoperative complications, and readmission rates were assessed.

RESULTS

Six hundred fifty-two patients underwent ACDF. For single-level ACDF, 222 were reviewed, with 112 having surgery at the beginning and 110 at the end of the week. For multilevel ACDF, 431 were reviewed, with 192 having surgery at the beginning and 239 at the end of the week. No differences in pre- or postoperative variables were determined for single-level ACDF. Despite no differences in pre-operative variables, CCI, operative duration, or number of levels, late-week multilevel ACDF had longer average LOS (2.8±3.0 days) compared to early-week surgery (2.0±2.0 days) ( P =0.018).

CONCLUSIONS

Late-week multilevel ACDF was associated with an increased LOS, as it may prove beneficial to surgical planning. This conflicts with previous reports that day of week was not associated with LOS following ACDF.

LEVEL OF EVIDENCE

III.

Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients

STUDY DESIGN/SETTING

A retrospective observational study.

OBJECTIVE

The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient.

SUMMARY OF BACKGROUND DATA

Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion.

MATERIALS AND METHODS

Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h).

RESULTS

In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management.

CONCLUSIONS

Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.

Assessing Root Causes of First Case On-time Start (FCOTS) Delay in the Orthopedic Department at a Busy Level II Community Teaching Hospital

INTRODUCTION

Due to the high cost of operating room time, hospitals have been under increasing pressure to optimize operating room (OR) efficiency. One parameter that has been used to predict OR efficiency is First Case On-Time Start (FCOTS). In this brief report, the authors describe results from a quality improvement project designed to identify the rates and primary causes of first case delay for elective procedures within the orthopedic department at their suburban community hospital.

METHODS

This was a retrospective, quality improvement project. The authors reviewed information from their anesthesia group to identify the rate and causes for delayed FCOTS, as well as observations and employee interviews to map contributing factors of delay.

RESULTS

Surgery data on 159 days reviewed indicated that 107 (67.3%) days had first case delays. Of the 398 total first cases during this period, 156 (39.2%) were found to be delayed. The authors identified surgeon practices, with 74 (56.5%) as the main contributor to delay, followed by pre-operative processes, with 24 (18.3%), and room-related causes, 17 (13.0%). The anesthesia department and the patient were minor causes of delay, with 9 (6.9%) and 7 (5.3%) of case delays respectively.

DISCUSSION

Results were similar to other studies, indicating surgeons and pre-operative as main cause for delay. A fishbone diagram revealed patient factors, inefficiency in the pre-operative process, and staff tardiness as some of the causes.

CONCLUSIONS

During this project, surgeon practices and preoperative processes were the main factors contributing to OR inefficiency within the community-based hospital. Future strategies to improve daily OR flow within similar institutions should target surgeon on-time arrival and streamlining of the pre-operative process to effectively reduce FCOTS delays.

Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF).

SUMMARY OF BACKGROUND DATA

Assessing postoperative inefficiencies is vital to increase the feasibility of ALF.

MATERIALS AND METHODS

Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge.

RESULTS

Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS.

CONCLUSIONS

Unavailability of PT, surgery after 1  pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge.

LEVEL OF EVIDENCE

4.

The impact of case order and intraoperative staff changes on spine surgical efficiency

BACKGROUND CONTEXT

Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency.

PURPOSE

This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases.

STUDY DESIGN/ SETTING

Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy.

OUTCOME MEASURES

Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions.

METHODS

Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups.

RESULTS

A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time.

CONCLUSIONS

Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.

Performing Multiple Posterior Spinal Fusions in 1 Day: A Comparison of Perioperative Outcomes Between Morning and Afternoon Cases

BACKGROUND

High-volume centers for idiopathic scoliosis (IS) have difficulty in scheduling posterior spinal fusions (PSFs) due to operating room availability, particularly during school vacation. A solution is for 1 surgeon to perform 2 PSF cases back-to-back. This study aims to compare morning and afternoon PSF cases performed by the same surgeon for perioperative outcomes.

METHODS

A retrospective review of PSF cases for IS that occurred on the same day as another PSF by the same surgeon between January 2013 and December 2019 was conducted. Perioperative outcomes included surgical time, estimated blood loss, length of stay, and inpatient opioid consumption normalized by the patient's weight. Postoperative outcomes included complications, revision rate, curve correction, and patient-reported outcomes using the Scoliosis Research Society-30.

RESULTS

A total of 95 patients (87% female), mean age 15.6 years, were analyzed, with 48 morning cases and 47 afternoon cases. The median follow-up was 1.9 years (range: 0.3 to 6.1 y). Tests for equivalency determined equivalence in median anesthesia and mean surgical duration (P=0.05). The groups had similar initial curve correction (P=0.43) and rate of complications at 90 days postoperative (2 in each group for a total of 4 complications). No significant differences were seen between Scoliosis Research Society-30 scores at 6 months or in those who have reached 2 years postoperative.

CONCLUSIONS

Little literature exists on the safety of a surgeon performing 2 PSF cases in 1 day, particularly in regard to pain outcomes, 30- and 90-day complication rates, and quality of life measures. This study indicates that few differences in safety, pain, and quality of life outcomes may appear between morning and afternoon PSF cases.

LEVEL OF EVIDENCE

Level II.

Surgical Start Time Impact on Hospital Length of Stay for Elective Inpatient Procedures

Background

Hospital length of stay (LOS) remains an important, albeit nonspecific, metric in the analysis of surgical services. Modifiable factors to reduce LOS are few in number and the ability to practically take action is limited. Surgical scheduling of elective cases remains an important task in optimizing workflow and may impact the post-surgical LOS.

Methods

Retrospective data from a single tertiary care academic institution were analyzed from elective adult surgical cases performed from 2017 through 2019. Emergent or urgent add-on cases were excluded. Variables included primary procedure, age, diabetes status, American Society of Anesthesiologists (ASA) class, and surgical start time. Analysis of the median LOS following surgery was performed using Mann-Whitney tests and Cox hazards model. Matched-cohort analysis of mean total hospitalization costs was performed using the Student’s t-test. 

Results

9,258 patients were analyzed across five surgical service lines, of which 777 patients had surgical start time after 3 PM. The median LOS for the after 3 PM group was 1 day longer than the before 3 PM start time cohort (3.0 vs 2.1, p < 0.001). Service line analysis revealed increased LOS for Orthopedics and Neurosurgery (3.0 vs 1.9, p < 0.001; 3.0 vs 2.0, p < 0.05). Multivariate analysis confirmed that start time before 3 PM predicted shorter LOS (HR = 1.214, 1.126-1.309; p < 0.001). Case-matched cost analysis for frequently performed orthopedic and neurosurgical cases with an after 3 PM start time failed to demonstrate a significant difference in total hospital charges. 

Conclusion

Optimization of surgical services scheduling to increase the proportion of elective surgical cases started before 3 PM has the potential to decrease post-surgical LOS for adult patients undergoing Orthopedic or Neurosurgical procedures. 

Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes

STUDY DESIGN

Retrospective analysis of clinical data from a single institution.

OBJECTIVE

The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy.

SUMMARY OF BACKGROUND DATA

The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy.

METHODS

Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates.

RESULTS

Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts.

CONCLUSION

The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.

Adult spinal deformity surgery: the effect of surgical start time on patient outcomes and cost of care

PURPOSE

There are reports investigating the effect of surgical start time (SST) on outcomes, length of stay (LOS) and cost in various surgical disciplines. However, this has not been studied in spine deformity surgery to date. This study compares outcomes for patients undergoing spinal deformity surgery based on SST.

METHODS

Patients at a single academic institution from 2008 to 2016 undergoing elective spinal deformity surgery (defined as fusing ≥ 7 segments) were divided by SST before or after 2 PM. Co-primary outcomes were LOS and direct costs. Secondary outcomes included delayed extubation, ICU stay, complications, reoperation, non-home discharge, and readmission rates.

RESULTS

There were 373 surgeries starting before 2 PM and 79 after 2 PM. The cohorts had similar demographics including age, sex, comorbidity burden, and levels fused. The late SST cohort had shorter operation durations (p = 0.0007). Multivariable linear regression showed no differences in LOS (estimate 0.4 days, CI - 1.2 to 2.0, p = 0.64) or direct cost (estimate $3652, 95% CI - $1449 to $8755, p = 0.16). Multivariable logistic regression revealed the late SST cohort was more likely to have delayed extubation (OR 2.6, 95% CI 1.4-4.9, p = 0.004) and non-home discharge (OR 2.2, 95% CI 1.1-4.2, p = 0.03). All other secondary outcomes were non-significant.

CONCLUSION

Patients undergoing spinal deformity surgery before and after 2 PM have similar LOS and cost of care. However, the late SST cohort had increased likelihood of delayed extubation and non-home discharges, which increase cost in bundled payment models. These findings can be utilized in OR scheduling to optimize outcomes and minimize cost.

Later Surgical Start Time Is Associated With Longer Length of Stay and Higher Cost in Cervical Spine Surgery

STUDY DESIGN

Retrospective study of a surgical cohort from a single, large academic institution.

OBJECTIVE

The aim of this study was to investigate associations between surgical start time, length of stay, cost, perioperative outcomes, and readmission.

SUMMARY OF BACKGROUND DATA

One retrospective study with a smaller cohort investigated associations between surgical start time and outcomes in spine surgery and found that early start times were correlated with shorter length of stay. No examinations of perioperative outcomes or cost have been performed.

METHODS

All patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) were queried from a single institution from January 1, 2008 to November 30, 2016. Patients undergoing surgery that started between 12:00 AM and 6:00 AM were excluded due to their likely emergent nature. Cases starting before and after 2:00 PM were compared on the basis of length of stay and cost as the primary outcomes using multivariable logistic regression.

RESULT

The patients undergoing ACDF and PCDF were both similar on the basis of comorbidity burden, preoperative diagnosis, and number of segments fused. The patients undergoing ACDF starting after 2 PM had longer LOS values (adjusted difference of 0.65 days; 95% confidence interval [CI]: 0.28-1.03; P = 0.0006) and higher costs of hospitalization (adjusted difference of $1177; 95% CI: $549-$1806; P = 0.0002). Patients undergoing PCDF starting after 2 PM also had longer LOS values (adjusted difference of 1.19 days; 95% CI: 0.46-1.91; P = 0.001) and higher costs of hospitalization (adjusted difference of $2305; 95% CI: $826-$3785; P = 0.002).

CONCLUSION

Later surgical start time is associated with longer LOS and higher cost. These findings should be further confirmed in the spine surgical literature to investigate surgical start time as a potential cost-saving measure.

LEVEL OF EVIDENCE

3.

Patient Characteristics and Surgical Start Time Affect Length of Stay Following Anterior Total Hip Arthroplasty

BACKGROUND

Currently, no consensus exists for selection criteria of appropriate candidates for outpatient total hip arthroplasty (THA). This study evaluates patient characteristics associated with same-day discharge, examined surgical start time's effect on rates of same-day discharge, and compares readmission and reoperation rates between groups.

METHODS

All patients who underwent a THA by one surgeon at a single quaternary care hospital between February 2016 and May 2018 were captured. All patients were given the option for same-day discharge. Patient characteristics and perioperative variables were analyzed.

RESULTS

A total of 429 patients met inclusion criteria, 153 (36%) were discharged on the day of surgery. In a multivariate analysis, age (P = .000), multiple comorbidities (P = .004), and start time remained statistically significant (P = .000). Patients with start times prior to 9 AM had odds ratio of 11.56 of being discharged same day when compared to those with start times after 12 PM. Patients discharged the day of surgery were less likely to have a 90-day emergency room visit (P = .010), a readmission within 30 days (P = .001) or 90 days (P = .000), or a reoperation (0 vs 14, P = .003).

CONCLUSION

Same-day discharge following THA is safe and feasible. Patient's age and number of comorbidities should be considered when developing selection criteria for same-day discharge programs. Patients selected for same-day discharge should receive earlier operating room start times.

Assessing Rapidity of Recovery After Cancer Surgeries in a Single Overnight Short-Stay Setting

BACKGROUND

In the short-stay surgery setting, where patients remain in hospital for a single overnight at most, it is unclear as to whether postoperative length of stay is a good surrogate for assessing rapidity of recovery. We hypothesized that length of stay would be a function of time of surgery and would be a poorer marker of recovery than time of discharge.

METHODS

A cohort of 891 mastectomy and 538 prostatectomy patients had a planned single overnight stay after surgery at an ambulatory surgical hospital during 2016. The relationship between surgical start time and postoperative length of stay or discharge time was assessed.

RESULTS

For both mastectomy and prostatectomy patients, 75% of patients were discharged between 10 AM and 12 noon and the median postoperative length of stay was 20 hours. There was a strong association between time of surgery and calculated length of stay. For mastectomies, having a surgery which begins at 6 PM vs 8 AM results in an estimated decrease of 8.8 hours (95% CI, 8.3-9.3) in postoperative length of stay but only 1.2 hours (95% CI, 0.77-1.6) later time of discharge. For prostatectomies, the estimated difference is a decrease of 6.9 hours (95% CI, 6.4-7.4) for postoperative length of stay and 2.5 hours (95% CI, 2.0-3.0) later discharge time.

CONCLUSIONS

Postoperative length of stay is a poor outcome measure in a short-stay setting. When assessing rapidity of recovery for single overnight stay patients, we advocate the use of discharge time with adjustment for surgery start time. The effect of surgery start time on both postoperative length of stay and discharge time should be investigated to ascertain which is best to assess rapidity of recovery in other ambulatory care settings where recovery involves a single overnight stay.

Retrospective Data Analysis and Literature Review for a Development of Enhanced Recovery after Surgery Pathway for Anterior Cervical Discectomy and Fusion

Objective

While enhanced recovery after surgery (ERAS) protocols are associated with shorter length of stay and improved outcomes in multiple surgical specialties, its application to spine surgery has been limited. Anterior cervical discectomy and fusion (ACDF) is a common spinal procedure with a relative efficacy and safety profile that makes it suitable for the application of ERAS principles. Reviewing our outcomes and practice and incorporating evidence-based clinical studies, we propose the development of an ERAS pathway for ACDF.

Methods

This is a retrospective review of ACDF cases performed at a single institution by a single surgeon from 2014 to 2017. Primary outcome measures included length of stay, complications, and 30-day readmission rates. The 1- and 2-level and the 3- and 4-level groups were also each consolidated into a single cohort for comparison. A comprehensive review of evidence-based literature pertaining to ACDF was then performed. Best-practice recommendations derived from the literature were incorporated into the proposed ERAS protocol.

Results

In this series of 75 1-level, 77 2-level, 44 3-level and 20 4-level ACDF procedures, the average surgical time (minutes) was 68, 90, 118 and 141; length of stay (days) was 1, 1, 1.4, and 1.7; drain usage (%) was 1.3, 2.6, 13.6 and 10; and 30-day readmission rates (%) were 2.7, 3.9, 4.5, and 15, respectively. Combining the 1- and 2-level as a single group and 3- and 4-level as another cohort, the 3- and 4-level cohort had a significantly higher rate of drain usage and estimated blood loss (EBL) but there was not a difference in length-of-stay, complications or 30-day readmission rates.

Conclusions

Given the relative equivalent safety profile between 1- and 2-level as compared to 3- and 4-level ACDF, the proposed ERAS pathway can be applied to all patients, and not just restricted to 1-level or 2-level ACDF. Taking into account feasibility parameters as deduced from a review of institutional outcomes, this pathway can streamline same-day discharge and improve the patient experience. Its success will be predicated on an iterative improvement process deriving from optimal prospective outcome measurements.

Back-to-Back Surgeries in AIS Patients Can be Performed Safely Without Compromising Radiographic or Perioperative Outcomes: A 10-year Review

STUDY DESIGN

A retrospective chart review of prospectively collected data.

OBJECTIVE

The aim of this study was to determine whether back-to-back scoliosis surgeries can be performed safely without compromising outcomes and the reproducibility of the practice between institutions.

SUMMARY OF BACKGROUND DATA

During the summer, spinal surgeons will often book multiple cases in one day. The complexity and demands of spinal fusion surgery call into question the safety. Change of operating room staff including anesthesiologists, nurses, and neurologists may introduce new risks.

METHODS

From 2009 to 2018, index AIS surgeries were included. In Groups 1, 2, and 3, surgeries were performed by a single surgeon. In Group 4, they were performed by other institutional surgeons. Group 1: first surgery of the day, Group 2: second surgery of the day, Group 3: only surgery of the day, Group 4: only surgery of the day by different institutional surgeon. Additional analysis was done to determine reproducibility after a surgeon was moved from Institution 1 to Institution 2.

RESULTS

Five hundred sixty-seven AIS patients were analyzed. Group 1 patients had similar radiographic outcomes compared with Group 2 (P > 0.05). Surgical time was similar (P = 0.51), but significantly more levels fused (P = 0.01). Compared with Group 3, Group 2 had a smaller preoperative Cobb (P = 0.02), shorter surgeries (P < 0.001), and length of stay (P = 0.04) but similar complication rate (P = 1). Compared with Group 4, Group 2 had smaller preoperative Cobb (P < 0.001), shorter surgery, and lower complication rate (P = 0.03). When determining reproducibility, institution 2 patients had significantly less blood loss, shorter surgeries, and shorter lengths of stay (P < 0.05).

CONCLUSION

Although long and involved, back-to-back AIS surgeries do not compromise radiographic or perioperative outcomes. Changes in operating team do not appear to impact safety, efficiency, or outcomes. This study also found that the practice is reproducible between institutions.

LEVEL OF EVIDENCE

3.

Does the Day of the Week Affect Length of Stay and Hospital Charges Following Anterior Cervical Discectomy and Fusion?

Background

To reduce the economic impact of excessive costs, risk factors for increased length of stay (LOS) must be identified. Previous literature has demonstrated that surgeries later in the week can affect the LOS and costs following joint arthroplasty. However, few investigations regarding the day of surgery have been performed in the spine literature. The present study attempts to identify the association between day of surgery on LOS and hospital charges following anterior cervical discectomy and fusion (ACDF) procedures.

Methods

A prospectively maintained surgical database of primary, level 1-2 ACDF patients between 2008 and 2015 was retrospectively reviewed. Patients were stratified by surgery day: early week (Tuesday) or late week (Friday) ACDF. Differences in patient demographics and preoperative characteristics were compared between cohorts using chi-square analysis or Student t test for categorical and continuous variables, respectively. Direct hospital costs were obtained using hospital charges for each procedure and subsequent care prior to discharge. Associations between date of surgery and costs were assessed using multivariate linear regression controlled for.

Results

Two hundred and ninety-five patients were included in the analysis. One hundred and fifty-three patients underwent early week ACDF, and 142 underwent late week ACDF. Surgery day cohorts reported similar baseline characteristics. There were no differences in operative characteristics or hospital LOS between cohorts. Additionally, no differences in total or subcategorical hospital costs were identified between surgery day cohorts.

Conclusions

Patients undergoing ACDF later in the week exhibit similar LOS and hospital costs compared to those undergoing ACDF early in the week. These results suggest that outpatient procedures with short postoperative stays are likely not affected by the changes in hospital work efficiency that occur during the transition to the weekend. As such, hospitals should not restrict outpatient procedures to specific days of the week.

Level of Evidence

3.