Patient's safety and satisfaction on same day discharge after robotic and laparoscopic radical prostatectomy versus discharge after 24 or 48 h: a longitudinal randomized prospective study.

BACKGROUND: There is a tendency of prompted global health systems to reduce the length of hospital stay without compromising patient safety or satisfaction. We evaluated the safety and viability of early discharge in patients undergoing minimally invasive radical prostatectomy (MIRP), as well as patient satisfaction with this strategy. METHODS: This longitudinal prospective study included 72 patients who underwent MIRP for prostate cancer. Three groups were performed according to the day of hospital discharge following surgery: same day (G1), first day after (G2), and second day after (G3). Satisfaction, adverse events, and readmission were analyzed for each group. Associations between clinicopathologic variables and same-day discharge were analyzed by comparing data between G1 patients who did and did not achieve same-day discharge. RESULTS: 16.7% of patients were not discharged according to randomization (10 randomized to G1). 80% of G1 patients who did not achieve same-day discharge had Gleason scores of 3 + 4 or 4 + 3, which were observed in 35.7% of patients discharged on the same day (P < 0.05). Average prostate weight was significantly lower in patients who achieved same-day discharge than in those who did not (P < 0.01). Univariable logistic regression points to Gleason scores of 3 + 4 or 4 + 3 as the main factors associated with unsuccessful same-day discharge (P < 0.05). There were no significant differences in satisfaction scores. CONCLUSIONS: Same-day discharge was both safe and feasible and does not appear to affect satisfaction in a subset of patients with prostate cancer. Surgeons should consider the Gleason score when determining whether same-day discharge is appropriate.

Outcomes of a Resident-Led Early Hospital Discharge Intervention.

BACKGROUND: Early morning patient discharge from the hospital is increasingly being recognized as a key dimension of quality of care. At our institution, there is a significantly lower early discharge rate on the teaching hospitalist teams in comparison with the non-teaching teams. OBJECTIVE: To implement a resident-driven intervention in the teaching medical services to increase overall discharge order rate before 11 am (DOB-11) and assess the effect of this intervention on hospital length of stay (LOS), 30-day readmission rates (RR), and resident perception. DESIGN: Interrupted time series as well as controlled before-after designs. PARTICIPANTS: All inpatients discharged from general medicine units. INTERVENTIONS: We implemented an educational didactic in conjunction with resident-attending daily walk rounds followed by resident-led multidisciplinary discharge huddles to identify next-day discharges. MAIN MEASURES: The primary outcome was DOB-11 rates 18 months pre- and 12 months post-intervention. SECONDARY OUTCOMES: LOS and RR. Additionally, we assessed residents' perception of the early discharge protocol. KEY RESULTS: The DOB-11 rate increased from 12 to 29% (p < 0.001), LOS increased by 1.47 days (P < 0.001), and RR increased by 0.32% (P = 0.84), respectively, on the teaching teams. Compared with the non-teaching (control) teams, the teaching teams registered a greater increase in DOB-11 rate (by 17%, p < 0.001; ratio of adjusted ORs 2.16; 95% CI, 1.65, 2.85; p value < 0.001), small increase in LOS (by 0.74 day, p = 0.39; ratio of adjusted post-/pre-intervention ratio [teaching] and post-/pre- intervention ratio [non-teaching] = 1.05, 95% CI, 0.97, 1.14, p = 0.23), and relative increase in RR (by 3.98%, p = 0.07, and ratio of ORs = 1.35, 95% CI, 1.03, 1.8), p = 0.03). Approximately 55% (16/29) of the residents agreed that the early discharge initiative helped in understanding the importance of prioritizing patients for early discharge. Additionally, 55% (20/36) of the residents "agreed" that the early discharge initiative compromised their learning during teaching rounds. CONCLUSION: Our study demonstrates that DOB-11 is an achievable goal, not only for non-teaching teams but also for resident-run teaching teams.

Safety of robotic-assisted gynecologic surgery and early hospital discharge in elderly patients.

BACKGROUND: A minimally invasive surgical approach has proven to decrease peri- and postoperative complications and shorten duration of hospital stay; however, there are limited data evaluating the safety of robotic-assisted surgery and early hospital discharge in the elderly population. Because age is a well-known, independent risk factor for perioperative morbidity and gynecologists treat many elderly patients, this is an important area of study. OBJECTIVE: The objective of the study was to evaluate discharge timing and surgical outcomes in elderly compared with younger patients undergoing robotic-assisted gynecologic surgery. STUDY DESIGN: This was a retrospective cohort study of all patients who underwent robotic-assisted gynecologic surgery at a high-volume, single institution from January 2013 through May 2016. Demographic information, discharge timing, and peri- and postoperative outcomes were compared for patients <65 years with those ≥65 years using univariate and multivariate analyses. RESULTS: There were 2757 patients included, with 2521 <65 years and 236 ≥65 years. Median age of the younger group was 42 years, while the median age of the elderly group was 69 years. Elderly patients had a higher body mass index (kilograms per square meter) (28 vs 26, P < .001) and higher American Society of Anesthesia classification (P < .001). Elderly were more likely to have malignancy as the indication for surgery (68% vs 11%, P < .001) and to undergo hysterectomy (81% vs 38%, P < .001) or surgery with lymph node dissection (44.5% vs 7.1%, P < .001). Elderly patients had a higher incidence of intraoperative complications (9% vs 4.6%, P = .002) and longer median hospital stay (17 vs 7 hours, P < .001) compared with younger patients. Same-day discharge was more common in younger patients (76% vs 45%, P < .001), and elderly patients were more likely to have admissions lasting >23 hours (13% vs 3%, P < .001) on univariate and multivariate analysis. Analysis of postoperative outcomes included 2023 patients with available postoperative data (80% of total population) (1794 <65 years, 229 ≥ 65 years). There were no differences between elderly and younger patients in overall postoperative complications, reoperations, intensive care unit admissions, emergency room visits, or hospital readmission within 6 weeks of surgery. CONCLUSION: Despite having more preoperative risk factors and more surgically complex procedures, elderly patients undergoing robotic-assisted gynecologic surgery had similar postoperative complication rates, and almost half of elderly patients were safely discharged the day of surgery. Our data suggest that robotic-assisted gynecologic surgery and early hospital discharge are safe in elderly patients.

Patients' satisfaction with fast-track surgery in gynaecological oncology.

This study investigates the experience and satisfaction with care of fast-tracked gynaecological patients. The Sydney Gynaecological Oncology Group, New South Wales, Australia, has previously shown the benefits of a fast-track surgery programme for gynaecology patients with both complex benign gynaecological pathology and gynaecological malignancy. The question of whether these benefits translate into a positive experience for fast-tracked patients, in the context of their hospital stay and healthcare team care, has not been previously explored in detail. A self-administered satisfaction questionnaire incorporating the European Organisation for Research and Treatment of Cancer (EORTC) cancer in-patient satisfaction with care measure (INPATSAT-32) questionnaire with additional questions was administered to 106 gynaecology participants at Royal Prince Alfred Hospital. Participants reported high levels of satisfaction with patient care and support received from doctors, ward nurses and the hospital as a service and care organisation, within the context of a fast-track surgical programme. Early hospital discharge after gynaecological surgery results in both enhanced recovery after surgery (ERAS) and high levels of patient satisfaction.

Evaluation of a safe neutrophil count for cessation of intravenous antibiotics and early hospital discharge in stable, afebrile patients recovering after acute myeloid leukemia therapy or an autograft.

Currently there are no guidelines on a safe neutrophil count(ANC) for intravenous antibiotic(IVAB) cessation and hospital discharge in patients recovering after febrile neutropenia(FN). We assessed the safety in selected patients after recent FN of prompt IVAB cessation and hospital discharge. Safety was defined as no fever recurrence after IVAB cessation and readmission in the 10-days post-discharge for infections.A retrospective, single center audit conducted on 92 adult hematology patients admitted with de novo acute myeloid leukemia (AML) for intensive chemotherapy or for an autograft. Most admissions (n = 128/141;91%) were complicated by FN. Half of FN episodes ceased IVAB promptly with a median(range) ANC of 0.6(0.1-4.9x109/L); none of these episodes had recurrent fever requiring IVAB resumption. Prompt discharge occurred in 45% overall. Subsequent unplanned readmission rates were low.In afebrile, stable AML and autograft patients without medico-social barriers to discharge, IVAB can be ceased and hospital discharges safely done ≤24h of ANC ≥ 0.2x109/L.

Early Hospital Discharge Using Remote Monitoring for Patients Hospitalized for COVID-19, Regardless of Need for Home Oxygen Therapy: A Descriptive Study.

AIM: Since beds are unavailable, we prospectively investigated whether early hospital discharge will be safe and useful in patients hospitalized for COVID-19, regardless of their need for home oxygen therapy. POPULATION AND METHODS: Extending the initial inclusion criteria, 62 patients were included and 51 benefited from home telemonitoring, mainly assessing clinical parameters (blood pressure, heart rate, respiratory rate, dyspnea, temperature) and peripheral saturation (SpO2) at follow-up. RESULTS: 47% of the patients were older than 65 years; 63% needed home oxygen therapy and/or presented with more than one comorbidity. At home, the mean time to dyspnea and tachypnea resolutions ranged from 21 to 24 days. The mean oxygen-weaning duration was 13.3 ± 10.4 days, and the mean SpO2 was 95.7 ± 1.6%. The nurses and/or doctors managed 1238 alerts. Two re-hospitalizations were required, related to transient chest pain or pulmonary embolism, but no death occurred. Patient satisfaction was good, and 743 potential days of hospitalization were saved for other patients. CONCLUSION: The remote monitoring of vital parameters and symptoms is safe, allowing for early hospital discharge in patients hospitalized for COVID-19, whether or not home oxygen therapy was required. Oxygen tapering outside the hospital allowed for a greater reduction in hospital stay. Randomized controlled trials are necessary to confirm this beneficial effect.

Propensity score-matched comparison of safety outcomes between high-risk and low-risk patients towards early hospital discharge after laparoscopic cholecystectomy.

Background: Laparoscopic cholecystectomy (LC), a common treatment for symptomatic gallstones, has demonstrated safety in low-risk patients. However, existing data are scarce regarding the safety of LC in high-risk patients and the feasibility of early hospital discharge. Materials and methods: This retrospective study included 2296 patients diagnosed with symptomatic gallstones who underwent LC at a tertiary care centre from January 2009 through December 2019. The authors employed propensity score matching to mitigate bias between groups. Statistical significance was set at P less than 0.05. Results: The median age of the patients was 56 years (range 46-67), with a mean BMI of 25.2±4.3 kg/m2. Patients were classified as: American Society of Anesthesiologists (ASA) I (19.7%), II (68.3%), III (12.0%), and IV (0%). ASA I-II included low surgical risk patients (88%) and ASA III-IV comprised high-risk patients (12%). The LC-related 30-day reoperative rate was 0.2% and the readmission rate was 0.87%. Nine patients (0.4%) sustained major bile duct injuries, resulting in a conversion rate of 2.4%. The postoperative mortality rate was 0.04%, and the mean hospitalization time was 3.5 days. Patients in the high-risk group with a history of acute cholecystitis exhibited greater estimated blood loss, longer operative times, and were significantly more likely to be in the longer-stay group. Conclusion: These findings suggest that LC can be conducted safely on high-risk patients, and early hospital discharge is achievable. However, specific factors, such as a history of acute cholecystitis, may result in prolonged hospitalization owing to increased blood loss and longer operative times.

Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early. / Menor mortalidad y reingreso en pacientes con pocas comorbilidades intervenidos de fractura de cadera y con alta precoz.

INTRODUCTION: Preoperative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge. MATERIAL AND METHODS: A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA ≤II were included for analysis and divided according to their postoperative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year postoperative mortality rates; 30-day postoperative hospital readmission rate; and medical or surgical cause were recorded. RESULTS: In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% vs 4.1%, P=.16) and 1-year postoperative (4.3% vs 16.3%, P=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% vs 16.3%, P=.037). CONCLUSIONS: In the present study, the early discharge group obtained better results 30-day and 1-year postoperative mortality indicators, as well as readmission for medical reasons.

[Translated article] Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early.

INTRODUCTION: Pre-operative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge. MATERIAL AND METHODS: A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA≤II were included for analysis and divided according to their post-operative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year post-operative mortality rates; 30-day post-operative hospital readmission rate; and medical or surgical cause were recorded. RESULTS: In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% versus 4.1%, p=.16) and 1-year post-operative (4.3% versus 16.3%, p=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% versus 16.3%, p=.037). CONCLUSIONS: In the present study, the early discharge group obtained better results 30-day and 1-year post-operative mortality indicators, as well as readmission for medical reasons.

Comparative analysis of infectious complications with outpatient vs. inpatient care for adults with high-risk myeloid neoplasm receiving intensive induction chemotherapy.

We recently reported an early hospital discharge (EHD) care strategy following intensive acute myeloid leukemia (AML)-like chemotherapy is safe. To evaluate its impact on infectious outcomes, we compared all adults treated from 8/1/2014 to 7/31/2018 discharging within 72 h of completing chemotherapy (EHD) with hospitalized patients (controls) across 354 induction and 259 post-remission cycles. While overall outcomes were similar, gram-positive bacteremias were more common in EHD patients than control (p<.001), although they received fewer days of IV antimicrobials (p< .001). Notably, cumulative infection risks in EHD patients were similar after induction and post-remission therapy. In multivariable analysis, only EHD status was independently associated with risk for gram-positive bacteremia (p= .01), whereas the only independent risk factor for fungal infection was fluconazole (vs. posaconazole) use (p< .001). The observation of increased rates of gram-positive bacteremias with EHD identifies improvements in catheter management as one area to further increase the safety of this care approach.

Desospitalização para cuidado domiciliar: impactos clínico e econômico da linezolida / Early hospital discharge for home care: clinical and economic impacts of linezolid

A tendência mundial pelo sistema de home care é uma estratégia de desospitalização. A assistência domiciliar favorece a redução dos custos operacionais dos serviços, na medida em que proporciona a diminuição do tempo médio de permanência nas instituições de internação, redução do número de reinternações, diminuição de complicações infecciosas sucedidas de hospitalizações prolongadas e aumento da adesão do paciente ao tratamento. A mudança da terapia endovenosa para a via oral permite a alta hospitalar precoce do paciente. A linezolida (Zyvox®) é um agente antibacteriano da classe das oxazolidinonas, indicado para o tratamento de infecções de pele e partes moles (IPPMs) e pneumonia adquirida em ambiente hospitalar ou comunitário. Devido à sua apresentaçãooral, pode ser uma opção para uso em home care para o tratamento de pacientes com infecções por cocos gram positivos resistentes aos beta-lactâmicos. As evidências disponíveis sobre o processo da desospitalização que avaliam o impacto clínico e econômico da linezolida mostram menortempo de hospitalização e alta precoce, além de menor custo total de tratamento, quando comparada a outras opções de tratamento. A linezolida mostra uma característica única no tratamento de infecções por Staphylococcus aureus resistentes à meticilina (MRSA), que é sua biodisponibilidade clinicamente semelhante entre as formas parenteral e oral, que possibilita a mudança da via de administração assim que o quadro clínico seja propício. Dessa forma, constata-se que a principal razão para a obtenção da economia é a possibilidade de oferecer um tratamento oral em regime domiciliar, realizado, até o momento, somente com a linezolida.

The global tendency of home care system is an early hospital discharge strategy. Home care assistance promotes a reduction in operating services costs, as it minimizes the mean of length hospital stay, reduces hospital readmissions, decreases infectious complications due to prolonged hospital stays and increases patient adherence to treatment. The switch therapy, from intravenous to oral allows an early hospital discharge. Linezolid (Zyvox®) is an antibacterial agent from the oxazolidinone class, indicated for the treatment of complicated skin and soft-tissue infection (cSSTI) and nosocomial or community-acquired pneumonia. Due to its oral administration, it may be an option for home care in the treatment of patients infected with beta-lactam-resistant Gram-positive cocci. The availableevidences about early hospital discharge that evaluate clinical and economic impacts of linezolid present shorter length of hospital stay and early discharge, as well as lower total cost of treatment, when compared to other treatment options. Linezolid shows an exclusive characteristic in infectionswith methicillin-resistant Staphylococcus aureus (MRSA) treatment, which is its bioavailability that is clinically similar between parenteral and oral administration, thereby allowing changes in the administration route as soon as the clinical presentation be adequate. Accordingly, it is observed that themain reason to economize is the possibility to offer an oral treatment in domiciliary care, performed, until now, only with linezolid.

Redução do tempo de hospitalização após cirurgia torácica de grande porte: identificação de fatores determinantes / Early discharge following major thoracic surgery: identification of related factors

Objetivo: Os custos da internação hospitalar têm relação direta com o tempo de permanência do paciente operado. Por outro lado, um menor tempo de internação permite aumentar a produtividade nos hospitais públicos com demanda reprimida. O objetivo deste estudo é identificar fatores determinantes da redução do tempo de internação pós-cirurgia torácica de grande porte. Método: Estudo retrospectivo por análise de prontuários, realizado em duas fases. Na fase I levantou-se uma série consecutiva de 169 pacientes divididos em grupo I (n=81) – operados no período de junho de 1990 a dezembro de 1995, e grupo II (n=88) – operados de janeiro de 1996 a maio de 2000, para verificação do tempo de internação e fatores relacionados. Na fase II levantou-se uma série consecutiva de 20 pacientes (grupo III) retroagindo a partir de março de 2002, para análise e comparação com uma pequena enquête enviada pela internet para 21 cirurgiões torácicos. Resultados: A quase totalidade dos pacientes prescindiu de UTI no pós-operatório imediato. O tempo de internação médio caiu de 7,6 dias (mediana 7) no grupo I para 5,1 dias (mediana 4) no grupo II (p<0,001). A utilização mais freqüente da analgesia epidural e o uso de vias de acesso menos traumáticas no grupo IIalcançou significância estatística (p<0,001). No grupo III o tempo de internação médio foi de 4,2 dias (mediana 4), com uso mais efetivo da analgesia epidural (75%) e emprego da toracotomia vertical (90%). Oito cirurgiões torácicos responderam à enquête: o tempo médio de internação informado variou de cinco a nove dias, todos os pacientes foram enviados para a UTI ou similar, e apenas dois cirurgiões usam de rotina toracotomia com preservação muscular. Conclusões: Este estudo confirma que o controle da dor e o menor trauma da via de acesso são fatores importantes para a mais rápida recuperação funcional dos pacientes. Sugere que uso da UTI pode ser restringido para pacientes com alto risco.

Background: There is a direct relation between hospital costs and hospital length of stay after the operation. On the other hand, reduced stay increases productivity of public hospitals with high service demanding. Our objective is to identify factors determining the decrease in hospital stay after major thoracic surgery. Methods: A two-phase retrospective study was conducted on analysis of medical records. In the first phase, data on length of hospital stay and related factors were collected from a consecutive series of 169 patientsdivided into group I (n=81) – patients operated on between June 1990 and December 1995, and group II (n=88) –patients operated on from January 1996 through May 2000. In the second phase, data were collected from a consecutive series of 20 patients (group III) starting backwards from March 2002, for analysis and comparison with an Internet survey sent to 21 thoracic surgeons. Results: Intensive care unitwas unecessary for most patients in immediate post operative period. The mean hospital stay decreased from 7.6 days (median 7) in group I to 5.1 days (median 4) in group II (p<0.001). The more frequent utilization of epidural analgesia and less traumatic thoracothomy in group II reached statistic significance (p<0.001). In group III, the mean hospital stay was 4.2 days (median 4), and there was a more efective use of epidural analgesia (75%) and muscle- sparing thoracothomy (90%). Eight thoracic surgeons answered the survey: the mean hospital stay varied from five to nine days and all patients were sent to intensive care or similar units. Only two surgeons utilize muscle-sparing thoracothomy. Conclusions: This study confirms that pain control and less traumatic surgical approach are important for faster functional recovery of patients. It suggests that the IC units may be used only for selected patients.