Same-Day Discharge Following Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis as a Measure of Quality in the Pediatric Population

Introduction

Acute appendicitis remains the most common illness requiring an urgent pediatric surgery, with a lifetime incidence of 8.6% in males and 6.7% in females. ¹ In the United States, more than 70,000 appendectomies are performed in children each year. ²

Laparoscopic appendectomy (LA), first described in 1977, ³ has become the standard of care for acute appendicitis in the last 20 years. Over the same two decades, hospital length of stay (LOS) after LA has decreased from several days to the common practice of overnight observation with next-day discharge (ND). As outcomes for pediatric LA have improved, focus is now shifted to improving the quality of care in other ways. More recently, multiple studies have demonstrated the feasibility and safety of same-day discharge (SD) in select pediatric LA patients.^4–7

The concept of value in healthcare and surgical care is multifactorial and has been expressed by the relationship, Value = Quality/Cost. ⁸ In terms of quality, numerous measures can influence the numerator of this equation, such as surgical outcomes, complication rates, and patient satisfaction. The intent of this study was to determine if SD following LA for children with uncomplicated appendicitis would improve the quality of care with respect to cost of treatment, patient satisfaction, and short-term complications or readmissions when compared with a contemporaneous cohort with ND.

Methods

With IRB approval, the charts of all pediatric patients who underwent LA for acute appendicitis by one of our four pediatric surgeons were reviewed between August 2012 and April 2015. Inclusion criteria included children, age 1–18 years, with uncomplicated appendicitis (acute appendicitis without perforation or gangrene) confirmed intraoperatively by the operating surgeon and thus eligible for discharge from the recovery room (SD). Exclusion criteria included children with evidence of perforation or gangrenous appendicitis or a medical indication for postoperative admission beyond the diagnosis of appendicitis. All patients were reviewed for demographics, comorbidities, LOS, and charges for their hospital encounter, including ER visit, laboratories/imaging, surgical procedure, complications, and postoperative hospitalization if any.

Patients and families were counseled preoperatively about the goal of discharge home from the recovery room if clinically appropriate, but no patient was refused admission for parental concerns or social considerations. Our standard protocol included IV antibiotics before incision, a three-port laparoscopic approach, with laparoscopic stapling of the appendix base and either stapler or cautery division of the mesoappendix. All patients received 0.25% bupivacaine at all port sites and the routine use of weight-based ketorolac (0.5 mg/kg up to maximum of 30 mg IV) at the conclusion of the procedure. Pain control for home included oral acetaminophen and ibuprofen, but no routine oral narcotics. Patients were deemed safe for discharge home from the recovery room using the same discharge criteria applied to patients discharged following elective same-day outpatient procedures through our Ambulatory Surgery Unit.

All patients' families were contacted by phone within 2 weeks of surgery to confirm there had been an uneventful recovery and to inquire about any issues that might require a follow-up visit in the office. For those patients discharged home from the recovery room, families were also mailed a six-question survey regarding their experience (Appendix 1).

Cost analyses were performed using the hospital cost accounting system and were based on total charges for the entire hospital encounter, including emergency room evaluation, diagnostics, operating room and surgical charges, and hospital admission where applicable. No adjustments were made to correct for inflation during the study period. Differences between the charges incurred by the two groups were tested with Student's t-test with significance at P < .05.

Results

From August 2012 through April 2015, a total of 304 children underwent appendectomy for appendicitis. Of these, perforated or gangrenous appendicitis was encountered in 68 patients (22%) who were admitted and treated based on a perforated appendicitis pathway, including additional antibiotics and ongoing evaluation, and were excluded from this study. The remaining 236 patients were eligible for the recovery room discharge pathway. Of these 236 acute appendicitis patients, 121 met criteria and were successfully discharged home from the recovery room (51%). The remaining 115 children were admitted to the hospital for observation, and all were discharged home the following day, with 15 of these children admitted before their operation due to unavailability of resources (OR, staff, and/or surgeon). There were no significant differences between SD and ND with respect to gender, age, or WBCs at presentation (Table 1).

Three patients were excluded due to comorbidities that contributed to an extended LOS: (1) a child with appendicitis while on therapy for leukemia, (2) a child with brittle diabetes, and (3) a child with a VP shunt and seizure disorder.

When we examined complications, there were no differences between the SD and ND groups (Table 2). Specifically, there were no superficial, deep, or organ space infections in either group. The four postoperative complications (one wound hematoma, one partial small bowel obstruction, and two ileus) seen in the cohort were not significantly different between groups.

As expected, LOS was significantly shorter for SD (11.8 ± 2.7 versus 24.8 ± 21.2 hours; P < .01). SD also did not result in a statistically significant difference from ND in terms of postoperative ER visits or readmissions (Table 2). The average length of time in the recovery room before discharge home was 2.5 ± 1.26 hours, with a range from 1 to 5.5 hours. Hospital charges between the two groups were compared for the entire initial hospital encounter, including emergency room evaluation, diagnostics, OR and surgical charges, and hospital admission where applicable. Comparison between these two groups revealed a significant average savings of $2140 for the SD group, P < .001 (Table 2).

With respect to patient satisfaction, surveys were sent to families of all SD patients, with a total of 32 responses (26% response rate; Table 3). When families were asked, “At the time of discharge, how did you feel about taking your child home the same day following surgery?” the majority (59%) responded, “Happy to go home,” and an additional 28% responded, “Nervous, but OK.” Overall, almost 80% replied that they would prefer to be discharged from the recovery room in similar circumstances in the future.

Discussion

To our knowledge, this is the first study for same-day discharge of pediatric acute appendicitis patients to show good family satisfaction surveys following discharge from the recovery room in addition to cost and LOS savings. Importantly, these results show that discharge from the recovery room saved patients thousands of dollars and an average of 13 hours in LOS without an increase in complications, ER visits, or postoperative readmissions.

Our findings are consistent with multiple studies published recently looking at pediatric same-day discharge pathways for uncomplicated appendicitis.^4–6,9–11 Skarda et al. developed a protocol for postoperative discharge following LA for uncomplicated appendicitis that utilized bedside nursing to evaluate for discharge readiness and elimination of postoperative antibiotics and were able to shorten LOS from 40 to 23 hours. ¹¹ Alkhoury et al. have demonstrated prospectively that SD following LA in children is both safe and achieves high family satisfaction.^4,5 The topic of discharge from the recovery room for uncomplicated appendicitis has also been the subject of a recent webinar open to all pediatric American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participants. Through collaboration among the member organizations, NSQIP aims to improve the standards and quality of care. With the development of a fast-track protocol, they demonstrated a significant reduction in postoperative admission and hospital charge reduction of more than $4000 per patient. ¹⁰ This is combined with the adult experience, with similar evidence for the safety of SD for acute appendicitis^12–16 and recent calls for a shift to have outpatient LA become the standard of care for adult uncomplicated appendicitis. ¹² As hospitals are able to provide the equivalent high-quality care at a reduced cost through economies of scale, improved processes, and efficient use of resources and time, they can also improve surgical and healthcare value.

Recently, there has also been increased discussion and investigation regarding the treatment of acute appendicitis nonoperatively.^7,17,18 Svensson et al. demonstrated initial successful nonoperative treatment of 22 of 24 children with acute appendicitis, with 62% of those randomized to nonoperative treatment avoiding appendectomy in the year of follow-up. ¹⁷ In this and other studies, nonoperative treatment arms required admission for intravenous antibiotics and monitoring for treatment failure. While nonoperative management was not part of this study, our results and others suggest that an appropriate comparator would be planned SD rather than admitting children after their LA, especially as there is a move to make this the new standard of care. This may significantly influence both hospital and societal cost analyses in comparing nonoperative with operative treatment.

There were several limitations in the current study. There was a relatively low response rate to the satisfaction surveys (26%), and these surveys were only sent to SD families, and therefore provided no means of comparison with ND. Additionally, while non-narcotic pain medicine was used preferentially in both groups, our practice is the standard use of scheduled IV ketorolac for appendectomy patients, which is not possible for SD patients, and the impact of this is not included in the present study. Given the retrospective nature of this study of clinical decision-making, there may be differences between the two groups that were not measured, introducing bias. The similarities in WBCs, age, and sex between the two groups make it unlikely that these preoperative characteristics determined admission. Notably, data were not collected on the rationale for admission of those who were not discharged. Given that SD was the default pathway for all nonperforated appendicitis patients, it would be important to determine if patients stayed because they failed to meet discharge criteria, due to parental preference, as a consequence of the time of presentation and operation, or other factors.

Another limitation is that the economic evaluation was done only from the perspective of hospital charges/insurance companies, without measurement of the societal costs incurred or avoided by both groups of patients. Although not directly measured, the fact that there was no increase in the rates of next-day PCP visits by SD patients suggests that the costs were not shifted significantly to clinics. Additionally, the costs to families for missed days of work and childcare for siblings during overnight stays would likely favor SD and increase cost-effectiveness, rather than decrease it. For each of the 121 patients discharged from the recovery room without occupying a floor bed, this also represents reclaimed bed capacity for other ill children, an unmeasured increase in efficiency.

Standards of care are established by a combination of historical experience and the best available evidence for alternative treatments. Although LA remains the most common, urgent, nonelective surgical procedure performed by pediatric surgeons, a combination of low complication rates, improved anesthesia, and uneventful postoperative observation admissions has generated more enthusiasm to treat uncomplicated appendicitis as a routine outpatient procedure. The present study suggests this to be a significant value added to the surgical treatment of appendicitis. Our hope is that as more favorable pediatric evidence accumulates for discharge on the day of surgery without admission for observation,^4,9,10,19 the standard of care will become same-day discharge, with the attendant health system cost savings and increased hospital capacity this will generate. This may serve as a new benchmark for appendicitis against which other emerging therapies, such as antibiotics alone, may be compared.