Enhanced recovery after minimally invasive gynecologic oncology surgery to improve same day discharge: a quality improvement project

Abstract

ObjectivesSame day discharge after minimally invasive hysterectomy has been shown to be safe and feasible. We designed and implemented a quality improvement perioperative program based on early recovery after surgery principles to improve the rate of same day discharge from 30% to 75% after minimally invasive gynecologic oncology surgery over a 12 month period.MethodsWe enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12 month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison of clinicodemographic variables and perioperative outcomes. A multidisciplinary team developed a comprehensive perioperative care program and followed quality improvement methodology. Patients were followed up for 30 days after discharge. A statistical process chart was used to monitor the effects of our interventions, and a multivariate analysis was conducted to determine factors associated with same day discharge.ResultsSame day discharge rate increased from 29% to 75% after implementation (p<0.001). The post-intervention cohort was significantly younger (59 vs 62 years; p=0.038) and had shorter operative times (180 vs 211 min; p<0.001) but the two groups were similar in body mass index, comorbidity, stage, and intraoperative complications. There was no difference in 30 day perioperative complications, readmissions, reoperations, emergency department visits, or mortality. Overnight admissions were secondary to nausea and vomiting (16%), complications of pre-existing comorbidities (12%), and urinary retention (8%). On multivariate analysis, longer surgery, timing of surgery, and narcotic use on the ward were significantly associated with overnight admission. Overall, 89% of patients rated their experience as ‘very good’ or ‘excellent’, and 87% felt that their length of stay was adequate.ConclusionsFollowing implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, our intervention significantly improved same day discharge rates while maintaining a low 30 day perioperative complication rate and excellent patient experience.

Carpe diemfor same-day discharge following minimally invasive gynecologic oncology surgery

“…Many have published their same-day discharge experience and outcomes and three important trends have emerged: more patients than ever before are willing to opt for, and in fact insist on, same-day discharge following minimally invasive surgery to decrease the risk of contracting nosocomial infections such as SARS-CoV-2; same-day discharge following minimally invasive surgery is feasible, efficient, and safe when a standardized, multidisciplinary care protocol is implemented; and same-day discharge decreases hospital resource utilization. [1][2][3] In their paper, Kim et al 1 outline a same-day discharge protocol implemented on a gynecologic oncology service for patients undergoing minimally invasive surgery at a tertiary cancer center during the first year of the pandemic. They saw a remarkable increase in same-day discharge from 30% to 75% with no impact on emergency room visits, 30-day readmission, re-operation, morbidity, or mortality rates.…”

“…Critically, same-day discharge was associated with high patient satisfaction and acceptance. 1 The same-day discharge protocol the group implemented is rooted in the canonical ERAS principles of standardized patient education and expectation setting, opioid-sparing analgesia, maintenance of euvolemia, and immediate post-operative ambulation and oral intake. Further, the same-day discharge protocol outlined an operations process to support successful outcomes including clear pre-operative eligibility criteria, scheduling same-day discharge at the start of the day, ensuring availability of an extended post-anesthesia care unit (PACU) stay or transfer to an observation unit with same-day discharge nursing care, objective discharge criteria, and a follow-up telephone call 24 to 72 hours after discharge.…”

“…With the SARS-CoV-2 pandemic, a rapid paradigm shift resulted in an almost overnight transition from inpatient stay to same-day discharge across the surgical specialties: robotic prostatectomy and nephrectomy, transcatheter aortic valve replacement, hip and knee arthroplasty, and mastectomy with immediate prosthetic reconstruction, to name a few. Many have published their same-day discharge experience and outcomes and three important trends have emerged: more patients than ever before are willing to opt for, and in fact insist on, same-day discharge following minimally invasive surgery to decrease the risk of contracting nosocomial infections such as SARS-CoV-2; same-day discharge following minimally invasive surgery is feasible, efficient, and safe when a standardized, multidisciplinary care protocol is implemented; and same-day discharge decreases hospital resource utilization 1–3…”

“…In their paper, Kim et al1 outline a same-day discharge protocol implemented on a gynecologic oncology service for patients undergoing minimally invasive surgery at a tertiary cancer center during the first year of the pandemic. They saw a remarkable increase in same-day discharge from 30% to 75% with no impact on emergency room visits, 30-day readmission, re-operation, morbidity, or mortality rates.…”

“…They saw a remarkable increase in same-day discharge from 30% to 75% with no impact on emergency room visits, 30-day readmission, re-operation, morbidity, or mortality rates. Critically, same-day discharge was associated with high patient satisfaction and acceptance 1…”