Same day discharge colon surgery: is it financially worth it?

AIM: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to the constraints posed by the COVID-19 pandemic. The aim of this study was to compare SDD and postoperative day 1 (POD1) discharge to understand the clinical outcomes and financial impact on factors such as cost, charge, revenue, contribution margin and readmission. METHOD: A retrospective review of colectomies was performed at a single institution over a 2-year period (n = 143). Two populations were identified: SDD (n = 51) and POD1 (n = 92). Patients were selected by International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) and Diagnosis Related Grouper (DRG) codes. RESULTS: There was a statistically significant difference favouring SDD in total hospital cost (p < 0.0001), average direct costs (p < 0.0001) and average charges (p < 0.0016). SDD average hospital costs were $8699 (values in USD throughout) compared with $11 652 for POD 1 (p < 0.0001), and average SDD hospital charges were $85 506 compared with $97 008 for POD1 (p < 0.0016). The net revenue for SDD was $22 319 while for POD1 it was $26 173 (p = 0.14). Upon comparison of contribution margins (SDD $13 620 vs. POD1 $14 522), the difference was not statistically significant (p = 0.73). There were no identified statistically significant differences in operating room time, robotic console time, readmission rates or surgical complications. CONCLUSIONS: Amidst the pandemic-related constraints, we found that SDD was associated with lower hospital costs and comparable contribution margins compared with POD1. Additionally, the study was unable to identify any significant difference between operating time, readmissions, and surgical complications when performing SDD.

The patient perspective of same day discharge colectomy: one hundred patients surveyed on their experience following colon surgery.

INTRODUCTION: Guided by enhanced recovery after surgery protocols and coerced by constraints of the Coronavirus Disease 2019, the concept of same day discharge (SDD) after colon surgery is becoming a topic of great interest. Although only a few literature sources are published on the topic and protocols, the number of centers interested in SDD is increasing. With the small number of sources on protocol, safety, implementation, and criteria, there has yet to be a review of the patient experience and satisfaction. METHODS: Our institution has one of the largest American databases of SDD colon surgery. We performed a retrospective patient survey assessing perception of their surgical experience and satisfaction, which analyzed patients from February 2019 to January 2022. Fifty SDD patients were selected for participation, as well as fifty patients who were discharged on postoperative day 1 (POD1). An eleven-question survey was offered to patients and responses recorded. RESULTS: One hundred patients were contacted, 50 SDD and 50 POD1. Of the SDD patients, 41/50 (82%) patients participated in the survey, while 23/50 (46%) of POD1 patients participated. The highest average response in both populations was an understanding of patient postoperative mobility instructions (9.27/10, 9.68/10). The lowest average response in the SDD population was family comfort with discharge (8.17/10), while patient comfort with discharge was lowest in the POD1 group, (8.56/10). Importantly, we observed that 85.37% of patients who underwent SDD would do so again if given the opportunity. The only statistically significant variable was a difference in comfort with postoperative pain control, favoring the POD1 group, p = 0.02. CONCLUSIONS: SDD colon surgery is a feasible and reproducible option. Only comfort with postoperative pain control found a statistical difference, which we intend to improve upon with postanesthesia care unit education. Of patients reviewed who underwent SDD, most patients enjoyed their experience and would undergo SDD again.

Beyond enhanced recovery after surgery (ERAS): Evolving minimally invasive colectomy from multi-day admissions to same-day discharge.

INTRODUCTION: Early discharge is increasingly important in the resource-limited COVID era. Some groups have reported early experiences with same day discharge (SDD) after colectomy. We implemented a routine SDD protocol and report the evolution in our program's outcomes. METHODS: We studied a retrospective cohort of robotic colorectal surgeries from 2016 to 2022. Colectomies were analyzed as a sub-group and stratified by year. RESULTS: The cohort comprised 535 cases, of which 483 were colectomies. Annual case volume increased from 58 to 180 cases (p < 0.001). Operative console time concordantly decreased by 33% (p < 0.001). Average length of stay decreased from five to one days. By 2022, 58% of colectomies were selectively discharged on the same day of surgery. Complication and readmission rates remained constant. CONCLUSIONS: SDD is feasible and safe in selected patients. We illustrate the practical evolution of a surgical practice toward routine SDD, and discuss the factors we found critical to this transition.

Ambulatory colectomy: a pathway for advancing the enhanced recovery protocol.

Enhanced recovery after surgery (ERAS) protocols employ multiple factors to decrease surgical stress and improve recovery (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012). These protocols use multimodal approaches to improve outcomes, including length of stay and morbidities (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012; Carmichael et al., Dis Colon Rectum 60:761-784, 2017). The ERAS guidelines have evolved since development; however, the question is posed of how to improve next (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012). With the success of ERAS, in combination with milestones made by minimally invasive surgery (MIS), it is our aim to describe the next step of same day discharge colectomy. Retrospective review was performed on all colectomies from February 2019 to January 2022. Same day discharge (SDD) was defined as admission less than 23 h and no overnight stay. Procedures were nonemergent and MIS. Patients were candidates SDD based on comorbidities, communication means, and social support. SDD candidacy continued if surgery was uncomplicated. Next, patients were required to achieve strict Post Anesthesia Care Unit (PACU) criteria for discharge. SDD patients were monitored via calls or messages until their first appointment. After analysis, 326 total colectomies were identified; based on inclusion and exclusion criteria, 115 patients underwent SDD, 35.3%. Of the 115 SDD, 5 patients returned to the emergency department, only 1 required readmission (0.9%). The most performed procedures were low anterior resection, 61 (53.0%), and right hemicolectomy, 25 (21.7%). Using ERAS protocols as a groundwork to improve upon, we identified several ways to advance select patients into SDD. Using strict patient selection, intraoperative regulations, and rigorous postoperative criteria, we found that SDD as an advancement of ERAS is a relatively safe procedure with minimal complications.

Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery.

BACKGROUND: Since its inception colectomy has routinely been performed in the inpatient setting. The advent of Enhanced Recovery After Surgery (ERAS) protocols has led improved outcomes, including decreased length of stay (LOS). These improvements have introduced the possibility of ambulatory colectomy. However, indications, protocols, and limitations of ambulatory colectomy have not been extensively explored. METHODS: We conducted a retrospective review on ambulatory colectomies performed between February 2019 and August 2021. Patients were candidates for same day discharge (SDD) if they met rigorous preoperative criteria. Following an uncomplicated operation, strict postoperative parameters were required for safe discharge. If the patient underwent SDD following their operation, they were monitored closely via telehealth visits and/or patient communication messages until their one-week postoperative visit. RESULTS: From our review, we identified sixty-nine (n = 69) patients who underwent SDD after colectomy. Of the 69, only one patient was readmitted after discharge (1.4%). All procedures were performed via a robotic-assisted approach (Da Vinci Xi). None of the patients underwent conversion to an open procedure. The most frequently performed procedures included: low anterior resection (LAR) (n = 32, 46.4%) and right hemicolectomy (n = 11, 15.9%). CONCLUSION: Through proper patient education and strictly defined communication between the patient care teams, safe and effective care in the setting of SDD after colectomy can be provided. With recent technological advancements, enhanced mechanisms for patient education throughout all phases, and emerging means of patient-physician communication, via the data included herein the opportunity for same day discharge (SDD) after colectomy is a feasible and safe management plan in the proper patient.