Promoting Same-Day Discharge for Gynecologic Oncology Patients in Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: Despite clear data demonstrating feasibility, safety, and cost-effectiveness of same-day discharge after minimally invasive hysterectomy, a paucity of data suggests ways to increase same-day discharge rates. Our objectives were to promote same-day discharge after minimally invasive hysterectomy using preoperative patient education videos, provider same-day discharge awareness initiatives, and standardization of postoperative management and to investigate reasons for overnight admission after surgery (non-same-day discharge). DESIGN: A quality improvement project measured rates of same-day discharge, patient satisfaction, and readmission during the 5 months before and after video implementation. Readmission rates were calculated as a surrogate for safety. A retrospective chart review was conducted of patients who underwent minimally invasive hysterectomy during the 5 months after video implementation, comparing 43 same-day discharges to 26 non-same-day discharge patients who met criteria for same-day discharge. Differences between groups were analyzed using 2-tailed t tests or logistic regression (continuous variables) and Fisher's exact test or χ2 test (categorical variables). Next, providers were educated about same-day discharge, and initiatives were implemented to standardize postoperative care. Same-day discharge rates were then calculated to evaluate these additional interventions (Canadian Task Force classification II-2). SETTING: A gynecologic oncology division based at an academic institution and performing surgery at 2 hospitals. PATIENTS: All patients undergoing minimally invasive hysterectomy for both benign and malignant disease, using robot-assisted, straight laparoscopic, and radical hysterectomy procedures. INTERVENTIONS: Patient education video, provider education about same-day discharge, and initiatives to standardize postoperative care. MEASUREMENTS AND MAIN RESULTS: Overall, same-day discharge rates decreased from 47% to 35% and readmission rates from 1.7% to 0% after video implementation. Greater than 87% of both groups were very or somewhat satisfied with their care (p = .71). Excluding patients who did not qualify for same-day discharge, the prevideo implementation same-day discharge rate was 72% (n = 78) and the postvideo implementation same-day discharge rate was 62% (n = 69). Higher patient complexity (p = .003), later case end time (p = .001), longer operative time (p = .001), and robot-assisted cases (p = .002) significantly predicted non-same-day discharge. After implementing initiatives to increase provider same-day discharge awareness and to standardize postoperative management, in addition to video implementation, the same-day discharge rate increased to 86% (n = 51). CONCLUSION: Same-day discharge in a select population is safe and feasible, with at least similar patient satisfaction as non-same-day discharge patients. Shorter operative time, earlier case end time, lower patient complexity, and non-robot-assisted approach increase the likelihood of same-day discharge. Patient education videos alone did not increase same-day discharges but maintained acceptable readmission rates. Communication with providers regarding the same-day discharge initiative and standardization of postoperative management with preoperative video implementation may lead to increased same-day discharge rates.

Characterization and treatment of patients with chronic rhinosinusitis and nasal polyps.

BACKGROUND: Patients with chronic rhinosinusitis (CRS) and nasal polyps (NPs) may be subdivided into aspirin-sensitive (AS) and aspirin-tolerant (AT) populations. These cohorts are not well characterized. OBJECTIVE: To examine phenotypic characteristics and determine the extent of medical/surgical interventions in patients with CRS+NP and to compare the AS with the AT subset in the CRS+NP sample. METHODS: Retrospective chart review was performed at a tertiary academic respiratory hospital. Data included patient demographics, asthma severity, peripheral eosinophilia, Lund-Mackay computed tomographic score, symptomatic dysosmia, and therapeutic interventions. RESULTS: Of the 182 patients included, 81 had aspirin sensitivity (45%) and 101 had aspirin tolerance (55%). Asthma was present in 94% of patients with CRS+NP (100% in AS subgroup vs 89% in AT subgroup, P = .001). Eighty-eight percent of the CRS+NP sample had moderate to severe persistent asthma. In the AS and AT subgroups, asthma severity was similar (P > .6). The CRS+NP sample showed a mean computed tomographic score of 14.0 (44% with eosinophilia and 46% with dysosmia). More severe sinus disease was noted in the AS group (Lund-Mackay computed tomographic scores, P = .002; olfactory symptoms, P = .001). Serum eosinophil levels were not statistically different between groups (51% in AS group, 39% in AT group, P > .1). CONCLUSION: This study is one of the broadest reviews of patients with CRS+NP, with unique findings in the high prevalence of asthma in AS and AT patients, greater olfactory dysfunction in AS patients, and a minority of patients with CRS+NP and circulating eosinophils. Most AS patients do not have increased circulating eosinophils, as is often believed. These results shed further light on the association between asthma and upper respiratory tract disease in those with nasal polyposis.

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis.

OBJECTIVE: (1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP. STUDY DESIGN: Case series with chart review. SETTING: Academic hospital specializing in respiratory and allergic disease. SUBJECTS: Patients with CRSwNP treated from 2008 to 2010. METHODS: Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity. RESULTS: Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05). CONCLUSIONS: Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.