FROM JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Outpatient laparoscopic surgery for uncomplicated appendicitis can be safely implemented in a large county hospital that serves a poor, underserved population, findings from a prospective, observational trial have shown.
Outpatient appendectomy has gradually gained acceptance in the United States, and numerous studies support the practice. David R. Rosen, MD, of the University of Southern California, Los Angeles, and his colleagues considered the possible advantages of outpatient laparoscopic appendectomy for their institution, such as decreased length of stay, decreased costs, and fewer admissions.
However, “in a large, safety-net teaching hospital caring for an undeserved public population, there were concerns among our surgeons that this protocol would not be effective,” Dr. Rosen and his colleagues explained. “Lack of communication, follow-up, and patient education were all cited as reasons that would cause this protocol to result in more postoperative complications and readmissions, negating any potential cost savings.”
The research team hypothesized that with a “well-defined protocol consisting of strict inclusion and exclusion criteria, clear patient instructions, and close observation to identify patients who would not succeed with the outpatient appendectomy treatment strategy, outpatient appendectomy would be feasible without worsening patient outcomes or satisfaction.”
The findings were published in the Journal of the American College of Surgeons ( 2017 May;224:862-7 ).
The investigators conducted a study of patients presenting at a safety-net county hospital and diagnosed with acute appendicitis. A year-long observation period produced a control group of 178 admitted patients.
The outpatient protocol was then introduced. Patients were counseled on the possibility of their being discharged from the postanesthesia care unit (PACU), depending on intraoperative findings and their capacity to arrange a ride home and willingness to participate in postoperative follow-up. Patient education was a key element of the protocol. In all, 173 patients were identified for the outpatient program.
The intraoperative criteria for discharge from the PACU included no evidence of perforation or gangrene, and no surgical complications or adverse events. Patients were cleared for discharge if they met the following criteria: heart rate less than 100 beats/min; systolic blood pressure greater than 110 mm Hg; pain well controlled (less than 4 on a 1-10 scale); ambulatory; urinated since surgery; oral intake; and dressings dry without evidence of bleeding.
The patients had been thoroughly briefed on what to expect and problems that would necessitate a return to the emergency department. The physician assessed each patient’s readiness to be discharged, wrote a discharge order, and confirmed the pain medication prescription and follow-up appointment.
Of the 173 patients selected for the outpatient program, 113 (65%) ended up being discharged from the PACU. The reasons for these admissions included interoperative findings, failure to pass the discharge criteria, homelessness, and no transportation to get home.
The control and outpatient groups were similar demographically, except that the latter were on average significantly older (mean age 32.4 years vs. 36.6 years, respectively). The outpatient group had a significantly shorter operative time (69 minutes vs. 83 minutes), a significantly longer stay in the PACU (242 minutes vs.141 minutes), and a significantly shorter total postoperative length of stay (9 hours vs.19 hours).
There were no differences between the groups in terms of complications, postdischarge ED visits, or readmissions. Those who were discharged from the PACU had no postoperative complications and no readmissions.
The length of stay in the PACU gradually decreased for the outpatient group. “This can be attributed to the adoption of a new protocol,” the researchers noted. However, “we purposely did not want to rush the discharge process to ensure our patients and families had all questions answered and were comfortable leaving the hospital.”
A key component of the protocol was the follow-up appointment for all appendectomy patients; about one-third of both groups did not return for their follow-up appointments. Those missed follow-ups could mean some patients returned to another hospital, but the investigators suggested that this was unlikely.
“Because our hospital serves a patient population of low socioeconomic status and often without health insurance, our public hospital is often the only hospital to which they would present,” the investigators wrote.
Most of those who did return completed a questionnaire on their level of satisfaction. Survey results showed no differences in satisfaction between the groups and a generally positive view of the protocol among the outpatient group.
The study did not account for actual cost savings, but reduced hospital admissions and readmissions were achieved. Investigators assert that other studies have shown that each day of hospitalization avoided saves about $1,900.
“It is challenging to deliver high-quality, efficient care to an underserved population in a public hospital,” Dr. Rosen said in an interview. “In this setting, communication and patient education are vital components for success. By setting clear expectations and empowering patients to participate in their care, we can maximize our patients’ outcomes.”
The investigators had no disclosures.