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Same-Day Discharge for Lap Colectomy Possible for Selected Patients Study Uses Remote Follow-up and Gives Patients Choice of Discharge or Admission By CHRISTINA FRANGOU
S
ome patients can be safely discharged home on the same day as their laparoscopic colectomy if they are followed remotely by a healthcare team, according to a study presented at the 2021 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons. Some surgeons and patients, however, say they worry about patients being rushed home before they feel ready. In a study carried out at two university-affiliated colorectal referral institutions, 79 out of 105 patients, or 75%, were successfully discharged on the day of their surgery. They were eligible for same-day discharge, or SDD, if they had no significant comorbidities, lived within 30 minutes of the hospital and did not require creation of a new ileostomy. Patients were asked if they preferred to go home or be admitted. All patients underwent remote follow-up with a mobile health app or daily telephone call from their surgeon. Two patients returned to the emergency department within 72 hours of discharge—one for urinary retention and the other with an anastomotic leak, which was managed conservatively. “Same-day discharge can be done safely with either an mHealth phone app or telephone calls for remote follow-ups, which significantly reduces the resource burden but with the same results,” said lead author Lawrence Lee, MD, PhD, an assistant professor of surgery, McGill University Health Centre, in Montreal, in an email to OR Management News. Co-investigator Jules Eustache, MD, a general surgery resident at McGill University, presented the study at SAGES. Overall, 10 patients, or 12.7%, returned to hospital within one month of surgery, consistent with previously published studies of colorectal surgery, said the investigators. The study started before the pandemic but picked up new urgency as COVID-19 put pressure on hospital systems. In the first wave, many patients were afraid to stay in the hospital, and Quebec’s ministry of health asked hospital staff to reserve capacity for patients with illnesses related to the virus, said Dr. Lee. As a result, SDD enabled more patients to have surgery that they otherwise would have waited for, said Dr. Lee. “It is not an exaggeration to say that a good proportion of our SDD patients would not have had their surgery done in a timely manner if the SDD hadn’t existed,” he said. The investigators set out to study SDD because McGill’s experience with an enhanced recovery after surgery protocol, or ERAS, showed that most of the patients remained in hospital after a laparoscopic colectomy only to pass gas. But research from other institutions demonstrated that patients could be safely discharged before their GI function returned.
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OR Management News • Volume 7 • March 2022
‘It just takes one patient having a major complication at home where they cannot get through to their provider or get fast-tracked through the emergency department, and that morbidity becomes a preventable mortality for this concept to go up in flames, so it is critical that implementation is appropriate.’ —Deborah S. Keller, MD The development of mHealth apps around the same time made remote post-discharge monitoring possible, said Dr. Lee. The investigators felt the combination of these principles suggested that SDD in these patients could be safe, he added. Patients underwent laparoscopic colectomy, using a Pfannenstiel incision when extraction was necessary. After surgery, patients spent four to six hours in the recovery room. To be discharged, they had to be able to tolerate a liquid diet, have their pain controlled with oral analgesia, and could ambulate and void independently after removal of any catheters. Patients were only discharged on the same day if they preferred to go home. The main reason for admission was patient preference, followed by intraoperative complications that required monitoring, nausea, poorly controlled pain and urinary retention. Patient Perspectives Should Be Considered By video at SAGES, Sue Blackwell, a patient working with the patient relations group of the Association of Coloproctology of Great Britain and Ireland, said patients want to stay in hospital until they felt ready to go home—“not when clinicians felt they were ready. If that was day 3, then great, but if it was day 10, then also great.” Deborah S. Keller, MD, an assistant professor of surgery at the University of California Davis Medical Center, said patients need to be asked if they are comfortable going home on the same day as their surgery. They often feel rushed by ERAS and SDD policies, she said. Dr. Keller said patients being discharged on the same day need in-depth communication with their surgeon and wearables that continued on page 22
