Patient Satisfaction After Outpatient Appendectomy

Introduction

The management of acute appendicitis continues to evolve. Since the introduction of laparoscopic appendectomy, multiple reports have found many advantages to laparoscopic surgery compared with the open technique, including decreased length of stay, less pain, and quicker return to full activities.^1–3 Recently, there have been several studies reporting that same-day discharge (SDD) is safe for patients who undergo a laparoscopic appendectomy for uncomplicated acute appendicitis.^4–6

In 2010, our institution implemented an outpatient protocol with laparoscopic appendectomy for the management uncomplicated acute appendicitis. ⁷ Patients who met predefined criteria were dismissed from the recovery room or day surgery unit. A total of 305 of 345 patients (88%) were treated on an outpatient basis. Overall morbidity was low (6.6%), and only 1% of patients required readmission. Patient dismissal occurred throughout the day and night-time hours and depended primarily on the time of presentation to the hospital. We concluded that outpatient management should be considered the new “standard of care” for uncomplicated appendicitis. ⁸

Several have questioned whether patient satisfaction with outpatient laparoscopic appendectomy is diminished compared with inpatient care, especially in patients who were dismissed at night. Patient satisfaction is an important component of quality care and has received renewed emphasis in patient care. Pay-for-performance metrics are linked to patient satisfaction. The objective of this study was to assess patient satisfaction with our outpatient protocol for laparoscopic appendectomy in uncomplicated appendicitis.

Materials and Methods

An institutional review board approved the study of patients who underwent laparoscopic appendectomy for uncomplicated acute appendicitis from January 2013 to October 2013. The study population included all patients at our institution who were discharged home from the postanesthesia care unit (PACU) after laparoscopic appendectomy as per the outpatient protocol. Exclusion criteria were age less than 18, pregnancy, and patients admitted to the hospital postoperatively. Patients who went to an inpatient room for a 23-hour observation were not categorized as SDD and, thus, were also excluded.

All patients underwent laparoscopic appendectomy with a three-trocar technique. Conversion to open appendectomy was left to the discretion of the attending surgeon. All operations were performed by the surgical resident staff with the attending surgeon's direct supervision. Trocar sites were injected with 10 mL of 0.25% bupivicaine hydrochloride with epinephrine. Patients were given 30 mg of ketorolac intravenously at the end of the procedure unless they had a clinical contraindication to administration. Postoperatively, patients recovered in the PACU.

They were given a full-liquid diet in the PACU and instructed to advance their diet at home as tolerated. Counseling on postoperative care and restrictions was given preoperatively with a preprinted instruction sheet that also included contact information and follow-up appointments. Prescriptions for postoperative analgesia were given to family members, and directions to the closest 24-hour pharmacy were provided for patients having surgery during the night. They were monitored until the following 10 discharge criteria were met:

 1. Ability to tolerate liquid intake.

Any patient with comorbidities that precluded the option of dismissal was admitted as deemed clinically necessary. In addition, selected operative interventions or complications could result in admission at the discretion of the attending surgeon and were considered failures of outpatient management. Demographic data were collected and included age and gender. Data on time of discharge, postoperative complications, and date that patients presented for follow-up were collected. Time of discharge from the recovery room was broken down into four groups: 6 a.m. to noon, noon to 6 p.m., 6 p.m. to midnight, and midnight to 6 a.m. A subset analysis of patient satisfaction corresponding to time of day was performed to see whether this impacted satisfaction. Patients were contacted by telephone by the primary investigator at 3–6 months postoperatively and asked to participate in a two-question survey regarding their recent surgery experience. We employed a Likert scale from 1 to 5, with 1 being very unsatisfied to 5 being very satisfied about how they felt about SDD after their appendectomy.

Patients were also queried whether, in retrospect, they would have made that choice if they could have been admitted to the hospital instead of going home. For those who stated that they would have preferred admission, we queried why they would have chosen admission.

Results

A total of 41 men and 31 women with an average age of 36 years (range 19–79 years) underwent outpatient laparoscopic appendectomy for uncomplicated appendicitis confirmed operatively and pathologically at our institution from January through October 2013. During this time frame, an additional 12 patients were found to have perforated or gangrenous appendicitis, and we excluded them from the outpatient protocol. Of these, 54 (75%) participated in a telephone satisfaction survey. Dismissal occurred from 6 a.m. to noon (24%), noon to 6 p.m. (17%), 6 p.m. to midnight (22%), and midnight to 6 a.m. (37%). The mean satisfaction score for outpatient management was 4.6 (range 2–5; SD +/−0.589). In the subset of patients dismissed between midnight and 6 a.m., patient satisfaction with outpatient therapy averaged 4.7. Six patients (11%) stated that they would have preferred hospitalization if given the opportunity. The reasons stated included inadequate pain control (2 patients); lack of home assistance (2 patients); nausea and vomiting after dismissal (1 patient); and prolonged drowsiness (1 patient). Four of these patients represented violations of the outpatient management guidelines (pain controlled on oral analgesics and adequate home assistance), and they should have been admitted by protocol criteria.

Discussion

Over the past 20 years, laparoscopic surgery has been applied to an ever-increasing number of operations. Because of the well-documented advantages of laparoscopic surgery, a number of procedures that formerly required postoperative admission are now performed on an outpatient basis. This includes outpatient laparoscopic cholecystectomy, hernia repair, bariatric procedures, fundoplication, and colectomy.^9–14 Application of outpatient management to laparoscopic appendectomy has lagged compared with other procedures, and the length of postoperative hospitalization ranges from 1 to 3 days in most series.

In the past 15 years, several studies have demonstrated that fast track pathways can be safely applied in selected patients with acute appendicitis. These studies developed criteria for dismissal within 1–3 days for both laparoscopic and open appendectomy.^9–11 Based on these studies and the ongoing trend toward outpatient management with laparoscopic surgery, other studies have adopted an outpatient approach either selectively or routinely for uncomplicated appendicitis. ¹² We did not include patient outcomes in the current article, as these have been previously reported and our focus was on patient satisfaction.^8,13 Overall, outpatient management was successful in 85% of patients with low morbidity and readmissions.

A patient's expectations of care and attitudes greatly contribute to satisfaction. ¹⁴

Presenting outpatient management in a positive light and communicating these plans at the initial discussion of surgery aids in setting patient expectations. Extensive preoperative counseling of patients and families that is often performed before elective surgery is more difficult due to the emergency nature of acute appendicitis. The surgical team must spend additional time explaining the rationale and benefits of outpatient management. It is important to redefine goals for the perioperative nursing and anesthesia personnel. This provides a team approach for the healthcare providers toward the goal of outpatient management. Our protocol included a patient instruction sheet with postoperative diet instructions, activity limitations, analgesic use, contact numbers for problems, directions to the local 24-hour pharmacy, and follow-up appointments (Appendix 1). Even when outpatient management has become a standard institutional practice, it is important to recognize that there are patients who will benefit from admission. This can occur due to medical and social/supportive needs. We adopted a set of criteria to gauge appropriateness of outpatient management, and we found that the guidelines were not followed in a minority of patients. Protocol violations accounted for 4 of the 6 patients who reported diminished patient satisfaction. Adherence to a set of outpatient management guidelines will help ensure that patients can appropriately be managed on an outpatient basis.

In an era in which physicians will be increasingly measured by the outcomes of their treatment, patient satisfaction will be increasingly measured as well. Previous research has shown a correlation between patient outcomes and patient satisfaction scores. Patient satisfaction is a major determinant of quality of care and an important component of pay-for-performance metrics. In conclusion, outpatient laparoscopic appendectomy can be performed with high patient satisfaction and acceptance. Night-time dismissal did not diminish patient satisfaction. Adherence to protocol guidelines for outpatient management is important to properly select patients for outpatient management and to maximize patient satisfaction.