Same-day discharge after major surgery is feasible, but safety concerns remain

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"In deciding whom to discharge within hours of a less invasive but major surgery, we must ask ourselves which master we are serving: the insurer, the administrator, or our own ego," writes Badar M. Mian, MD.

Badar M. Mian, MD

Badar M. Mian, MD

Same-day discharge (SDD) after surgery is being utilized with increasing frequency after minimally invasive surgery in urology and other specialties for procedures such as radical prostatectomy (RP), partial nephrectomy (PNx), colectomy, and lung resection. Although the surgical approach may be minimally invasive, many of the procedures are considered major interventions with potential for serious complications. In a recent study, Epstein et al evaluated whether the trend of SDD comes at the expense of patient safety following urological surgery.1

The investigators focused on the timing of major adverse events (AEs) after RP and PNx using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. They defined major early AEs as the proportion of blood transfusions, cardiac arrests, myocardial infarctions, and deaths that occurred within 2 days of SDD, as well as within 30 days. They analyzed the timing of occurrence of these events to determine whether employing an SDD policy, instead of an observation period, could result in potentially delayed detection of these complications.

According to the ACS-NSQIP database, from 2015 to 2019, 41,379 patients underwent laparoscopic RP and 16,896 underwent laparoscopic PNx. Of these, 600 (1%) were discharged on the same day as surgery during this period. The aforementioned complications within 30 days of the index operation were reported in 4154 (7.1%) patients, readmissions were reported in 2611 (4.5%) patients, reoperations in 774 (1.3%) patients, and deaths in 79 (0.14%) patients.

Notably, more complications occurred within 48 hours after surgery than any other 48-hour period postoperatively, including 188 of 2611 readmissions (7%), 84 of 774 reoperations (11%), 908 of 979 transfusions (93%), 82 of 209 myocardial infarctions (39%), 39 of 81 cardiac arrests (48%), and 12 of 79 deaths (15%).

The authors are not reporting on minor complications such as fever, infection, or gastrointestinal problems but rather on potentially life-threatening events. These data on the timing of severe complications suggest that a period of observation is warranted for certain patients undergoing a minimally invasive surgery that has the potential for devastating complications.

Those who have implemented an SDD program for various procedures often identify selection criteria for patients who are good candidates for SDD. These include preoperative (comorbidities) and intraoperative (surgical complexity) criteria that could place the patient at increased risk of postoperative complications. Few studies report that additional infrastructure and support staff are required in the recovery room to achieve SDD and in the clinic to manage postoperative care after SDD. Other considerations for SDD include patient’s social support network, distance from the medical center, a good insurance plan, and the means to travel and/or stay at a nearby hotel. As such, it is important to recognize that SDD is not suitable for all patients because the enticing literature on the feasibility and safety of SDD is enriched with selected patients and only in certain settings.

For those patients who meet the criteria for SDD (healthy, lower risk, no immediate complications), the risk of major complications is still the highest in the postoperative day 2, according to data presented by the authors. To increase the confidence in the safety of SDD, additional evaluation provided in a nonacute setting might go a long way. For example, a preplanned home visit (live or virtual) by a qualified nurse or an office visit with a nurse or advanced practice provider on day 2 could identify potentially serious complications before those become major emergencies. This type of program would incur some ongoing cost and require planning, monitoring, and a budget.

SDD following surgery does not eliminate the need for ongoing care, and the duty to care for the postsurgical patient does not end with discharge. There is a shifting of patient care workload, and the associated cost, to the nonhospital, outpatient setting. The burden of care shifts to the office staff and the inbox of the physician, who must then manage an increasing number of questions, medications, and studies that otherwise would have been addressed by the hospital team. This usually happens without allocating additional resources such as administrative or nursing staff. In other words, the burden (and cost) of care is absorbed by the nonhospital setting, and the purported cost savings do not materialize for the physicians or the departments.

Although the benefits of SDD, including cost savings, fewer hospital-acquired infections, and increased patient satisfaction, are often reported, there is rarely a mention of the major early (albeit low rate) complications. It is unclear how patients would react to SDD if the risks of potentially major complications occurring soon after discharge were also disclosed to them simultaneously. The approach of SDD after such surgical procedures requires prospective evaluation in a randomized trial to determine its true impact on patient outcomes and cost of care.

SDD has become a marketing tool, and it is often advertised as a market differentiator for hospitals and medical practices. The pressure to not occupy a hospital bed comes from multiple directions, including the hospital administration, health insurance plans, and academic competition. In deciding whom to discharge within hours of a less invasive but major surgery, we must ask ourselves which master we are serving: the insurer, the administrator, or our own ego. We must remain faithful to our true constituents—our patients, who entrust us with their well-being, and sometimes their lives.

REFERENCE

1. Epstein M, Helstrom E, Correa A. Balancing patient safety and early postoperative discharge: an American College of Surgeons National Surgical Quality Improvement Program analysis of postoperative complications after minimally invasive urologic surgery. J Urol. 2024;211(1):174-176. doi:10.1097/JU.0000000000003724

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