Using frailty to predict who will fail early discharge after laparoscopic colorectal surgery with an established recovery pathway.

BACKGROUND: Despite laparoscopy and enhanced recovery pathways, some patients do not attain early discharge. Frailty is generally accepted as a marker of increased risk, complications, and mortality. Frailty may have the potential to identify patient outcomes. PURPOSE: The aim of this study was to evaluate frailty as a predictor of patients who might fail early discharge. SETTING: This study was conducted at a tertiary referral center. DESIGN: This was a case-matched study. PATIENTS: Elective abdominal laparoscopic colorectal cases from 2009 to 2012 were selected. METHODS: Review of a prospective database matched all cases with a postoperative day of discharge of ≤3 days to a >3 day of discharge cohort. All patients followed a standardized enhanced recovery pathway. STATISTICAL ANALYSIS: Categorical and ordinal variables were analyzed with the Student t test or Fisher exact test, and correspondence analysis evaluated the relationship between length of stay and the Modified Frailty Index. MAIN OUTCOME MEASURE: The primary outcome measure was the relationship between length of stay and the Modified Frailty Index. RESULTS: There were 464 ≤3 day and 388 >3 day patients. The groups were similar in demographics and comorbidities. There were significant differences in the Modified Frailty Index (p < 0.01), operative time (p < 0.01), postoperative complications (p < 0.01), 30-day readmissions (p = 0.03), and 30-day reoperation rate (p < 0.01). Significantly more patients were discharged home in the ≤3 day cohort. Correspondence analysis demonstrated a higher Modified Frailty Index was indicative of longer length of stay. A Modified Frailty Index of 0 was strongly related to a length of stay 0 to 3 days, and a Modified Frailty Index of 2 was strongly related to a 8- to 14-day stay. LIMITATIONS: This was a single-center study performed on a retrospective data set. CONCLUSIONS: Patients undergoing elective colorectal surgery with a higher Modified Frailty Index were more likely not to attain early discharge. Despite similar demographics, the Modified Frailty Index could discriminate between patient outcomes, and correlated with longer operating times, length of stay, and readmissions. By using a prospective score to identify patients at risk for not achieving early discharge preoperatively, resources and postoperative support can be better allocated.

Predicting who will fail early discharge after laparoscopic colorectal surgery with an established enhanced recovery pathway.

BACKGROUND: Despite using laparoscopy and enhanced recovery pathways (ERP), some patients are not ready for early discharge. The goal of this study was to identify predictors for patients who might fail early discharge, so that any defined factors might be addressed and optimized. METHODS: A prospectively maintained database was reviewed for major elective laparoscopic colorectal surgical procedures. Cases were divided into day of discharge groups: ≤ 3 days and >4 days. All followed a standardized ERP. Demographic and clinical data were compared using Student's paired t tests or Fisher's exact test, with p value < 0.05 statistically significant. Regression analysis was performed to identify significant variables. RESULTS: There were 275 ≤ 3 days patients and 273 >4 days patients. There were significant differences between groups in body mass index (p = 0.0123), comorbidities (p = 0.0062), ASA class (p = 0.0014), operation time (p < 0.001), postoperative complications (p < 0.001), and 30-day reoperation rate (p = 0.0004). There were no significant differences for intraoperative complications (p = 0.724), readmissions (p = 0.187), or mortality rate (p = 1.00). Significantly more patients were discharged directly home in the ≤ 3-days cohort. Using logistic regression, every hour of operating time increased the risk of length of stay >4 days by 2.35 %. CONCLUSIONS: Elective colorectal surgery patients with longer operation times and more comorbidities are more likely to fail early discharge. These patients should have different expectations of the ERP, as an expected 1- to 3-day stay may not be achievable. By identifying patients at risk for failing early discharge, resources and postoperative support can be better allocated and patients better informed about likely recovery.

Therapy dogs in the emergency department.

INTRODUCTION: This study examined acceptance by staff and patients of a therapy dog (TD) in the emergency department (ED). METHODS: Immediately after TD visits to a University Hospital ED, all available ED staff, patients, and their visitors were invited to complete a survey. RESULTS: Of 125 "patient" and 105 staff responses, most were favorable. Ninety-three percent of patients and 95% of staff agreed that TDs should visit EDs; 87.8% of patients and 92% of staff approved of TDs for both adult and pediatric patients. Fewer than 5% of either patients or staff were afraid of the TDs. Fewer than 10% of patients and staff thought the TDs posed a sanitary risk or interfered with staff work. CONCLUSION: Both patients and staff approve of TDs in an ED. The benefits of animal-assisted therapy should be further explored in the ED setting.