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Safety and feasibility of same-day discharge for uncomplicated appendicitis: A prospective cohort study
Journal of Pediatric Surgery 53 (2018) 988–990
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Safety and feasibility of same-day discharge for uncomplicated appendicitis: A prospective cohort study Kristin Gee a, Sandra Ngo a, Lorrie Burkhalter a,b, Alana L. Beres a,b,⁎ a b
University of Texas at Southwestern, Dallas, TX, United States Children's Health, Dallas, TX, United States
a r t i c l e
i n f o
Article history: Received 14 January 2018 Accepted 1 February 2018 Key words: Same day discharge Appendectomy Pediatric Ambulatory surgical procedure Appendicitis
a b s t r a c t Background: Appendicitis is the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain, and hospital stay after laparoscopic procedures have been significantly reduced. While many laparoscopic procedures are performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis. Methods: After IRB approval, all pediatric patients undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis were eligible for the study. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times, outcomes of complications, readmissions, return to the ED, and nonscheduled clinic visits were collected. Results: A total of 1321 appendectomies were performed during the study period, of which 849 were uncomplicated and 382 were discharged same day. There were 2 readmissions, 4 superficial surgical site infections, 10 patients with nausea or vomiting, and 33 patients with pain control issues, 9 of whom presented to the ED. Conclusions: Same day discharge for laparoscopic noncomplicated appendectomy is a safe and feasible alternative to postoperative admission and observation. This has the potential to yield significant healthcare cost savings. Level of Evidence: Level II, Prospective Cohort Study. Published by Elsevier Inc.
Appendicitis is the most common gastrointestinal pediatric surgical emergency [1]. With the introduction of laparoscopic techniques in the early 1990s, pain, incidence of wound infection, and length of hospital stay for patients undergoing laparoscopic procedures have been significantly reduced [2,3]. Studies including both children and adults have suggested that same-day discharge is safe for most patients with nonperforated appendicitis undergoing appendectomy via laparoscopic approach [4,5]. It is now routinely done in the adult population at some institutions [6,7]. While many laparoscopic procedures such as cholecystectomy [8] and incisional hernia repair [9] are routinely performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Through the end of 2015, our institution routinely admitted all patients undergoing appendectomy for postoperative monitoring. We noted that, regardless of day or night timing of surgery, laparoscopic appendectomy (LA) patients with uncomplicated acute appendicitis were largely discharged the following morning after an uneventful night of observation. This led to variable lengths of stay from eight to more than 24 h postoperatively for ⁎ Corresponding author at: Children's Health, 1935 Medical District Drive, D-2000, Dallas, TX 75235. E-mail address: [email protected] (A.L. Beres). https://doi.org/10.1016/j.jpedsurg.2018.02.031 0022-3468/Published by Elsevier Inc.
the same process. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis at our institution. We proposed that the complication rate in our population after same day discharge would be low. 1. Methods After institutional review board approval (# STU 082015–081), all otherwise healthy pediatric patients ages 2 to 18, undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis at our institution were eligible for the study. All patients with perforated or gangrenous appendicitis were excluded from the study, as were those undergoing interval appendectomy. Patients who underwent uncomplicated appendectomy but were found intraoperatively to have additional abdominal pathology (i.e. torsed ovarian cyst) were excluded from the study. Decision for same day discharge was based on surgeon preference and parental agreement. All surgeons in our practice participated in the study. Patients who were discharged postoperatively from either the inpatient floor or the Post Anesthesia Care Unit (PACU) were included in the study. “Same day discharge” was considered a discharge on the same calendar day that the surgery was performed. All patient demographics including gender, age, race, and discharge location were
K. Gee et al. / Journal of Pediatric Surgery 53 (2018) 988–990 Table 1 Demographics. Feature
Number (Percent)
Sex Male Female Age 0–6 7–12 13–18 Race Caucasian or White Black or African American Asian Hispanic Other Unknown Discharge Location PACU Floor
235 (62%) 147 (38%) 41 (11%) 216 (57%) 125 (32%) 256 (68%) 21 (5%) 9 (3%) 37 (9%) 38 (10%) 21 (5%) 139 (36%) 243 (64%)
recorded (Table 1). Patients were followed for the entirety of the 12month study period to assess for complications (follow up range 2 weeks–1 year). The median follow up was two weeks. All complications including surgical site infection, abscess, nausea and/or vomiting, intractable pain, readmissions, return to the emergency department and nonscheduled clinic visits were recorded. Standard follow-up included a phone call 2 weeks postoperatively, where pain, healing, appetite, and return to normal activities were assessed. A clinic visit was offered and usually declined. 2. Results A total of 1321 appendectomies were performed during the study period; 961 were uncomplicated, of which 382 (40%) were discharged the same day, either from PACU (36%) or the floor (64%). The majority of our patients were male (62%) and identified as Caucasian (68%). Most of our patients were between 7 and 12 years of age (57%). There were two readmissions during the study period: one for intractable pain and one intraabdominal abscess. There were four superficial surgical site infections: two were diagnosed on presentation to the emergency room for wound drainage and the other two were diagnosed after the patient's caregiver emailed a photo of the incision to the clinic. There were ten patients who presented to the emergency department (ED) with postoperative nausea and vomiting and seven of these were
Fig. 1. Patient outcomes.
989
diagnosed with constipation on abdominal x-ray. All ten of those patients were discharged from the ED after adequate symptom control. There were 33 patients with pain control issues, 9 of whom presented to the ED and were discharged after symptom control (Fig. 1). The other 24 patients with pain control issues called the clinic specifically to discuss their child's pain. In total, there were 22 patients (5.8%) who presented to the emergency room, 21 patients who requested extra clinic visits, and 2 readmissions. 3. Discussion A 2010 meta-analysis comparing laparoscopic to open surgical approaches to acute appendicitis showed many benefits of the minimally invasive approach, including shorter hospital stays, earlier return to baseline activity and diet, and decreased postoperative pain [10]. Additionally, in a pediatric population, another meta-analysis showed significant decreases in wound infection and ileus without a significant increase in development of intraabdominal abscess [2]. These favorable outcomes have led to the routine use of laparoscopy for appendectomies. Given the expeditious recovery with the laparoscopic approach, some institutions propose discharge after day surgery for eligible patients, much like the shift to outpatient surgical management of cholecystectomies. In an institutional retrospective review from 2010 to 2012, this protocol for laparoscopic appendectomies was successful with only 1% readmission rate in an adult population [6]. In our study of 382 pediatric patients, the readmission rate was 0.5%. This is comparable to other studies of pediatric patients with same-day discharge after undergoing laparoscopic appendectomies (many using single-incision approach) with readmission rates of 2.5% (2012, 162 patients) [4] and 0.7% (2014, 128 patients) [5]. Our study also supports low incidence of complications. Of the 22 (5.8%) patients presenting to the emergency department and 21 (5.5%) patients requesting additional clinic visits, 4 had a surgical-site infection, 10 had nausea or vomiting, and 33 had pain control issues. Despite low rates of complications, some surgeons are hesitant to adopt a routine same-day discharge protocol. Historically, at our institution, patients with acute appendicitis were observed inpatient postoperatively. Some surgeons routinely saw patients for a postoperative clinic visit. In recent years, follow-up has predominantly been through telephone calls at two weeks after the operation, during which parents are asked questions to evaluate for complications or concerns. With fewer clinic visits and overnight admissions, same-day discharge has the potential to improve efficiency and reduce costs. In an institutional study of a “fast-track” protocol, there was a decrease in resource use and reduced median hospital charge without compromising safety [11]. In previous studies of parental satisfaction, 92% [12] and 95% [4] of parents reported feeling pleased with same-day discharge. Our institution serves a large metroplex and surrounding areas with patients who have diverse levels of access to care. The study was limited review of our electronic record and thus does not account for complications presenting to outside providers. We feel that it is unlikely that a large number of complications would be missed and would introduce bias. In our health care system patients presenting to adult centers are almost universally transferred, even for minor issues. Also, our center is the only pediatric center to treat patients with Medicaid or no insurance. Loss to follow up is possible; only 50% of our families responded to the 2-week follow up phone call, either at the time of the call or returning our call. This is our standard phone follow up rate. Families are provided with a phone number to reach a member of the surgical team 24 h per day if they have concerns. Though several previous studies have shown same day discharge after uncomplicated laparoscopic appendectomy in the pediatric population is safe, these studies had much smaller patient cohorts than our institution [13,14]. Given our study institution has a large volume of patients requiring surgery for acute appendicitis, current postoperative management could be further optimized by comparing the incidences
990
K. Gee et al. / Journal of Pediatric Surgery 53 (2018) 988–990
of complications in patients discharged on the same calendar day to those discharged after an inpatient observation period. Additional studies of institutional resource utilization may support a new protocol that comments on same-day discharge for eligible pediatric patients with uncomplicated acute appendicitis. References [1] Guthery SL, Hutchings C, Dean JM, et al. National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 Kids' Inpatient Database. J Pediatr 2004;144(5):589–94. [2] Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 2006;243(1):17–27. [3] Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2004;4:CD001546. [4] Alkhoury F, Malvezzi L, Knight CG, et al. Routine same-day discharge after acute or interval appendectomy in children: a prospective study. Arch Surg 2012;147(5): 443–6. [5] Aguayo P, Alemayehu H, Desai AA, et al. Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis. J Surg Res 2014; 190(1):93–7.
[6] Frazee RC, Abernathy SW, Davis M, et al. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis. J Trauma Acute Care Surg 2014;76(1):79–82 [discussion −3]. [7] Scott A, Shekherdimian S, Rouch JD, et al. Same-day discharge in laparoscopic acute non-perforated appendectomy. J Am Coll Surg 2017;224(1):43–8. [8] Gould JL, Poola AS, St Peter SD, et al. Same day discharge protocol implementation trends in laparoscopic cholecystectomy in pediatric patients. J Pediatr Surg 2016; 51(12):1936–8. [9] Saia M, Mantoan D, Buja A, et al. Increased rate of day surgery use for inguinal and femoral hernia repair in a decade of hospital admissions in the Veneto Region (north-east Italy): a record linkage study. BMC Health Serv Res 2013;13:349. [10] Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional appendectomy–a metaanalysis of randomized controlled trials. BMC Gastroenterol 2010;10:129. [11] Farach SM, Danielson PD, Walford NE, et al. Same-day discharge after appendectomy results in cost savings and improved efficiency. Am Surg 2014;80(8):787–91. [12] Alkhoury F, Burnweit C, Malvezzi L, et al. A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg 2012;47(2):313–6. [13] Grewal H, Sweat J, Vazquez WD. Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery. JSLS 2004;8(2):151–4. [14] Halter JM, Mallory B, Neilson IR, et al. Same-day discharge following laparoscopic appendectomy for uncomplicated acute appendicitis as a measure of quality in the pediatric population. J Laparoendosc Adv Surg Tech A 2016;26(4):309–13.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Safety and feasibility of same-day discharge for uncomplicated appendicitis: A prospective cohort study Kristin Gee a, Sandra Ngo a, Lorrie Burkhalter a,b, Alana L. Beres a,b,⁎ a b
University of Texas at Southwestern, Dallas, TX, United States Children's Health, Dallas, TX, United States
a r t i c l e
i n f o
Article history: Received 14 January 2018 Accepted 1 February 2018 Key words: Same day discharge Appendectomy Pediatric Ambulatory surgical procedure Appendicitis
a b s t r a c t Background: Appendicitis is the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain, and hospital stay after laparoscopic procedures have been significantly reduced. While many laparoscopic procedures are performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis. Methods: After IRB approval, all pediatric patients undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis were eligible for the study. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times, outcomes of complications, readmissions, return to the ED, and nonscheduled clinic visits were collected. Results: A total of 1321 appendectomies were performed during the study period, of which 849 were uncomplicated and 382 were discharged same day. There were 2 readmissions, 4 superficial surgical site infections, 10 patients with nausea or vomiting, and 33 patients with pain control issues, 9 of whom presented to the ED. Conclusions: Same day discharge for laparoscopic noncomplicated appendectomy is a safe and feasible alternative to postoperative admission and observation. This has the potential to yield significant healthcare cost savings. Level of Evidence: Level II, Prospective Cohort Study. Published by Elsevier Inc.
Appendicitis is the most common gastrointestinal pediatric surgical emergency [1]. With the introduction of laparoscopic techniques in the early 1990s, pain, incidence of wound infection, and length of hospital stay for patients undergoing laparoscopic procedures have been significantly reduced [2,3]. Studies including both children and adults have suggested that same-day discharge is safe for most patients with nonperforated appendicitis undergoing appendectomy via laparoscopic approach [4,5]. It is now routinely done in the adult population at some institutions [6,7]. While many laparoscopic procedures such as cholecystectomy [8] and incisional hernia repair [9] are routinely performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Through the end of 2015, our institution routinely admitted all patients undergoing appendectomy for postoperative monitoring. We noted that, regardless of day or night timing of surgery, laparoscopic appendectomy (LA) patients with uncomplicated acute appendicitis were largely discharged the following morning after an uneventful night of observation. This led to variable lengths of stay from eight to more than 24 h postoperatively for ⁎ Corresponding author at: Children's Health, 1935 Medical District Drive, D-2000, Dallas, TX 75235. E-mail address: [email protected] (A.L. Beres). https://doi.org/10.1016/j.jpedsurg.2018.02.031 0022-3468/Published by Elsevier Inc.
the same process. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis at our institution. We proposed that the complication rate in our population after same day discharge would be low. 1. Methods After institutional review board approval (# STU 082015–081), all otherwise healthy pediatric patients ages 2 to 18, undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis at our institution were eligible for the study. All patients with perforated or gangrenous appendicitis were excluded from the study, as were those undergoing interval appendectomy. Patients who underwent uncomplicated appendectomy but were found intraoperatively to have additional abdominal pathology (i.e. torsed ovarian cyst) were excluded from the study. Decision for same day discharge was based on surgeon preference and parental agreement. All surgeons in our practice participated in the study. Patients who were discharged postoperatively from either the inpatient floor or the Post Anesthesia Care Unit (PACU) were included in the study. “Same day discharge” was considered a discharge on the same calendar day that the surgery was performed. All patient demographics including gender, age, race, and discharge location were
K. Gee et al. / Journal of Pediatric Surgery 53 (2018) 988–990 Table 1 Demographics. Feature
Number (Percent)
Sex Male Female Age 0–6 7–12 13–18 Race Caucasian or White Black or African American Asian Hispanic Other Unknown Discharge Location PACU Floor
235 (62%) 147 (38%) 41 (11%) 216 (57%) 125 (32%) 256 (68%) 21 (5%) 9 (3%) 37 (9%) 38 (10%) 21 (5%) 139 (36%) 243 (64%)
recorded (Table 1). Patients were followed for the entirety of the 12month study period to assess for complications (follow up range 2 weeks–1 year). The median follow up was two weeks. All complications including surgical site infection, abscess, nausea and/or vomiting, intractable pain, readmissions, return to the emergency department and nonscheduled clinic visits were recorded. Standard follow-up included a phone call 2 weeks postoperatively, where pain, healing, appetite, and return to normal activities were assessed. A clinic visit was offered and usually declined. 2. Results A total of 1321 appendectomies were performed during the study period; 961 were uncomplicated, of which 382 (40%) were discharged the same day, either from PACU (36%) or the floor (64%). The majority of our patients were male (62%) and identified as Caucasian (68%). Most of our patients were between 7 and 12 years of age (57%). There were two readmissions during the study period: one for intractable pain and one intraabdominal abscess. There were four superficial surgical site infections: two were diagnosed on presentation to the emergency room for wound drainage and the other two were diagnosed after the patient's caregiver emailed a photo of the incision to the clinic. There were ten patients who presented to the emergency department (ED) with postoperative nausea and vomiting and seven of these were
Fig. 1. Patient outcomes.
989
diagnosed with constipation on abdominal x-ray. All ten of those patients were discharged from the ED after adequate symptom control. There were 33 patients with pain control issues, 9 of whom presented to the ED and were discharged after symptom control (Fig. 1). The other 24 patients with pain control issues called the clinic specifically to discuss their child's pain. In total, there were 22 patients (5.8%) who presented to the emergency room, 21 patients who requested extra clinic visits, and 2 readmissions. 3. Discussion A 2010 meta-analysis comparing laparoscopic to open surgical approaches to acute appendicitis showed many benefits of the minimally invasive approach, including shorter hospital stays, earlier return to baseline activity and diet, and decreased postoperative pain [10]. Additionally, in a pediatric population, another meta-analysis showed significant decreases in wound infection and ileus without a significant increase in development of intraabdominal abscess [2]. These favorable outcomes have led to the routine use of laparoscopy for appendectomies. Given the expeditious recovery with the laparoscopic approach, some institutions propose discharge after day surgery for eligible patients, much like the shift to outpatient surgical management of cholecystectomies. In an institutional retrospective review from 2010 to 2012, this protocol for laparoscopic appendectomies was successful with only 1% readmission rate in an adult population [6]. In our study of 382 pediatric patients, the readmission rate was 0.5%. This is comparable to other studies of pediatric patients with same-day discharge after undergoing laparoscopic appendectomies (many using single-incision approach) with readmission rates of 2.5% (2012, 162 patients) [4] and 0.7% (2014, 128 patients) [5]. Our study also supports low incidence of complications. Of the 22 (5.8%) patients presenting to the emergency department and 21 (5.5%) patients requesting additional clinic visits, 4 had a surgical-site infection, 10 had nausea or vomiting, and 33 had pain control issues. Despite low rates of complications, some surgeons are hesitant to adopt a routine same-day discharge protocol. Historically, at our institution, patients with acute appendicitis were observed inpatient postoperatively. Some surgeons routinely saw patients for a postoperative clinic visit. In recent years, follow-up has predominantly been through telephone calls at two weeks after the operation, during which parents are asked questions to evaluate for complications or concerns. With fewer clinic visits and overnight admissions, same-day discharge has the potential to improve efficiency and reduce costs. In an institutional study of a “fast-track” protocol, there was a decrease in resource use and reduced median hospital charge without compromising safety [11]. In previous studies of parental satisfaction, 92% [12] and 95% [4] of parents reported feeling pleased with same-day discharge. Our institution serves a large metroplex and surrounding areas with patients who have diverse levels of access to care. The study was limited review of our electronic record and thus does not account for complications presenting to outside providers. We feel that it is unlikely that a large number of complications would be missed and would introduce bias. In our health care system patients presenting to adult centers are almost universally transferred, even for minor issues. Also, our center is the only pediatric center to treat patients with Medicaid or no insurance. Loss to follow up is possible; only 50% of our families responded to the 2-week follow up phone call, either at the time of the call or returning our call. This is our standard phone follow up rate. Families are provided with a phone number to reach a member of the surgical team 24 h per day if they have concerns. Though several previous studies have shown same day discharge after uncomplicated laparoscopic appendectomy in the pediatric population is safe, these studies had much smaller patient cohorts than our institution [13,14]. Given our study institution has a large volume of patients requiring surgery for acute appendicitis, current postoperative management could be further optimized by comparing the incidences
990
K. Gee et al. / Journal of Pediatric Surgery 53 (2018) 988–990
of complications in patients discharged on the same calendar day to those discharged after an inpatient observation period. Additional studies of institutional resource utilization may support a new protocol that comments on same-day discharge for eligible pediatric patients with uncomplicated acute appendicitis. References [1] Guthery SL, Hutchings C, Dean JM, et al. National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 Kids' Inpatient Database. J Pediatr 2004;144(5):589–94. [2] Aziz O, Athanasiou T, Tekkis PP, et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 2006;243(1):17–27. [3] Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2004;4:CD001546. [4] Alkhoury F, Malvezzi L, Knight CG, et al. Routine same-day discharge after acute or interval appendectomy in children: a prospective study. Arch Surg 2012;147(5): 443–6. [5] Aguayo P, Alemayehu H, Desai AA, et al. Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis. J Surg Res 2014; 190(1):93–7.
[6] Frazee RC, Abernathy SW, Davis M, et al. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis. J Trauma Acute Care Surg 2014;76(1):79–82 [discussion −3]. [7] Scott A, Shekherdimian S, Rouch JD, et al. Same-day discharge in laparoscopic acute non-perforated appendectomy. J Am Coll Surg 2017;224(1):43–8. [8] Gould JL, Poola AS, St Peter SD, et al. Same day discharge protocol implementation trends in laparoscopic cholecystectomy in pediatric patients. J Pediatr Surg 2016; 51(12):1936–8. [9] Saia M, Mantoan D, Buja A, et al. Increased rate of day surgery use for inguinal and femoral hernia repair in a decade of hospital admissions in the Veneto Region (north-east Italy): a record linkage study. BMC Health Serv Res 2013;13:349. [10] Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional appendectomy–a metaanalysis of randomized controlled trials. BMC Gastroenterol 2010;10:129. [11] Farach SM, Danielson PD, Walford NE, et al. Same-day discharge after appendectomy results in cost savings and improved efficiency. Am Surg 2014;80(8):787–91. [12] Alkhoury F, Burnweit C, Malvezzi L, et al. A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg 2012;47(2):313–6. [13] Grewal H, Sweat J, Vazquez WD. Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery. JSLS 2004;8(2):151–4. [14] Halter JM, Mallory B, Neilson IR, et al. Same-day discharge following laparoscopic appendectomy for uncomplicated acute appendicitis as a measure of quality in the pediatric population. J Laparoendosc Adv Surg Tech A 2016;26(4):309–13.