in urology surgery department at the Main University Hospital, determining proportion of ... It is also called ambulatory or outpatient surgery and it refers to any.
Appropriateness of Length of Hospital Stay for Patients Undergoing One-Day Urology Surgery Hanan A. Alkorashy†, El-Mahalli A A.‡, Hamdy S.M.N.¶ † Hanan A. Ezzat, Lecturer, Nursing Administration, Faculty of Nursing, Alexandria University. ‡ Azza El-Mahalli, Lecturer of Health Administration & Planning, High Institute of Public Health, Alexandria University. ¶ Saif Al-Eslam Mahmood Hamdy, Professor, Urology Surgery Dept., Faculty of Medicine, Alexandria University.
Abstract: One day surgery has developed over the past 3 decades for a number of reasons including advanced managing care and health maintenance organizations, improved surgical instruments, less invasive surgical techniques, availability of a team approach in preparing a person for surgery and home recovery and the desire to reduce health care costs. The present study aimed at assessing the Pre-decided one day surgeries among patients admitted in urology surgery department at the Main University Hospital, determining proportion of inappropriate days of hospitalization, and uncovering reasons associated with inappropriate utilization of hospital stay. Among 1607 reviewed records, 800 (49.78%) cases were decided to be conducted as one-day surgeries. Concerning the total Length of Stay (LOS), findings revealed that only 10.6% of these days were appropriate89.4% of the reviewed hospital days were inappropriate and can be managed for more efficient and effective care provision. Premature admission, weekends and problems in scheduling surgery were the reasons of inappropriate preoperative stay, while doing diagnostic procedures and/or treatment that can be done on an outpatient basis and lack of family for home care, were found to be reasons for postoperative stay.
Introduction: Surgical intervention is evolving and developing, giving a variety of operative options to the surgeon and to the patient. Many of the current innovations have contributed to one day surgery (1-4). It is also called ambulatory or outpatient surgery and it refers to any surgical procedure for which the patient is admitted and discharged on the same day. In the United States, more than 60% of elective surgeries are currently performed as one day surgeries. Health experts expect that this percentage will increase to nearly 75% over the next decade.(5) One day surgery has developed over the past 3 decades for a number of reasons including advanced managing care and health maintenance organizations,(6) improved surgical instruments, less invasive surgical techniques, availability of a team approach in preparing a person for surgery and home recovery health care costs.
(7-9)
(5)
and the desire to reduce
Recently, people with more complex medical problems are scheduled
for one day surgery, and types and complexity of surgeries have expanded significantly.(5) Early discharge from hospital after surgery is safe and is well accepted by patients.(10-12) One day surgery seems to enhance the opportunity for social support within the family and may facilitate discussion of the illness with the family members,(2) recovery in the patient’s own environment results in better psychological adjustment as a result of enhanced patient 1
comfort, control, independence, and better interaction with family members.(13) Also, children benefit significantly from one day surgery as it decreases separation from their family and home.(14) One day surgery reduces medications prescribed, uses the doctor’s time more efficiently and does not increase the incidence of wound infection.(2) Moreover, long hospital stay is detrimental for patients as hospitals are not safe and patients are at risk for developing infections
(15)
, having bad reactions to medications,(6) or, having difficulty
in re-entering the real world, as well as exposure to have a higher rate of unemployment. (9) On the other hand, long stay patients utilize a considerable proportion of inpatient hospital resources. This may be an inappropriate over or under utilization of acute care resources when patients could be discharged home. (16) The aim of the present study was to: 1. Identify acceptable one-day surgeries for patients admitted in urology surgery department as recommended by surgeons. 2. Determine days of hospitalization among patients admitted for any of the recommended one-day surgeries scheduled in 2004. 3. Identify reasons associated with current inappropriate hospital stay for patients scheduled for any of recommended one-day surgeries.
Methodology: Setting: The study was conducted at the medical record department and the urology surgery department. at Alexandria Main University Hospital.
Subjects:
Surgeons: Twenty four urology surgeons from urology department, faculty of medicine including professors, assistant professors, lecturers, assistant lecturers and residents conducting various types of urology surgeries participated in the study;
Patients: One hundred patients admitted, and scheduled for recommended oneday surgeries, were involved in the study process,
Tools: Three tools were used to collect data: 1. One-Day Surgery Opinnionnaire Sheet: was designed to reflect the surgeons' opinion regarding the surgical procedures which are to be performed in one-day basis. The list of surgeries was derived from the pertaining literature (17, 18).
2
2. Retrospective Surgery Review Sheet: was developed to gather the required information through auditing medical records over one year, 2004. Data collected included patient's age, gender, source of admission (OPC or RR), final diagnosis, intervention, and dates of admission, operation and discharge.
3. Appropriateness of Hospital Stay Sheet: This tool was derived from Appropriateness Evaluation Protocol (AEP)
(19)
. The AEP is an international protocol intended to
assess if the admission, and hospitalization days, are appropriate or not, and reasons of appropriateness and inappropriateness for each. The Appropriateness of Hospital Stay Sheet was designed to identify the reasons of inappropriate hospitalization days among patients planned to do one-day surgical procedures. Data included were patient's age, gender, admission date and source, provisional and final diagnosis, date of the operation, date of discharge, appropriateness of each hospitalization day, and reason(s) for inappropriate preoperative and postoperative hospital stay. Method of data collection: After the official approvals were obtained, data were collected in two phases: a. Retrospective Review Phase:
In order to examine the applicability of conducting the selected surgical procedures, as reflected in literature, in one-day surgery system in the study setting, the urology surgeons were asked to complete the "One-Day Surgery Opinnionnaire". Twenty four faculty members responded. Agreement of 70% or more of the participants was a criterion for considering the surgical procedure applicable to be conducted as a one-day surgery.
All medical records of the patients admitted to the urology surgery department through out the year 2004 were obtained and reviewed, using the "Retrospective Surgery Review Sheet". The total number of records was 1607. The surgical procedures were categorized as either of one-day or multi-days types.
b. Prospective Phase:
Monitoring of 100 patients admitted to the department, and scheduled for any of the recommended one-day surgeries, was done over a period of two months. Their records were being reviewed daily from the day of admission till discharge. Each day was assessed for its appropriateness/inappropriateness of stay in urology department. Reasons for inappropriateness either preoperatively or postoperatively were assessed for each inappropriate day. 3
Statistical Analysis: SPSS version 11.5 was used for data entry and analysis. The retrospective Analysis focused on classifying patients according to intervention, either one-day surgery, multi-day surgery, or cases with no surgical intervention but stayed for receiving treatment, diagnostic procedures, or follow-up. In case of operative interventions, preoperative, postoperative, and total Length of Stay (LOS) were calculated to determine inappropriate days. The LOS for each patient was determined by subtracting the date of admission from the date of discharge when the patient was admitted and discharged within one month, adding days as necessary when the patient’s stay extends over one or more month endings. Moreover, preoperative stay was calculated by subtracting date of admission from the date of the operation, whereas postoperative stay was calculated by subtracting preoperative stay from the LOS and average LOS was computed as total LOS divided on total discharges. Results: a) Retrospective review: Table 1 illustrates the Urology surgical procedures recommended by surgeons to be regarded as one-day surgeries. It included those procedures reported by 70 % of the involved surgeons or more. Nephrostomy tube insertion, Orchidectomy, Prostate biopsy, Testicular biopsy, Extracorporeal Stock Waves Lithotripsy and Varicocelectomy were recommended by all surgeons to be conducted as one-day procedure, while Bladder biopsy was recommended by only 79.17% of the surgeons.
Table 2 illustrates Characteristics of the patients admitted to Urology Surgery Department in year 2004. It was found that more than 50% of the involved patients were aging more than 40 years old (19% were more than 60 years old). Majority of patients were males (74.45%) and were mainly admitted to the unit through the outpatient clinic (92.8%). Twenty three percent of subjects discharged without undergoing a surgical procedure, though they received medical treatment, investigations done and/or other diagnostic procedures (23.1%). About half of the reviewed records were had belonged to patients scheduled for one-day surgery (49.8%), and 27.1 % were admitted for multi-days surgeries.
Table 3 shows distribution of subjects according to their age, gender and type of intervention. The table indicates that the difference among the three interventions were statistically significant in both gender and age. For gender, 78.6% of the patients scheduled for one-day surgeries were males (X2 = 16.898, P < 0.05), while in relation to age, patients who were scheduled for one-day surgeries were significantly older than those scheduled for 4
longer stays, (X = 42.1220.76 years, 38.35±18.77 years, 32.89±22.66 years) respectively. (F = 25.512, P < 0.05).
Table 4 shows the distribution of subjects' hospital days according to the intervention. It indicated that the total length of hospital stay for reviewed subjects (7515 days) representing 41.05% of the total length of stay for all subjects (18305 days), and that only 10.65% of these days were appropriate. Moreover, for surgical procedures that should consume not more than one day of hospital stay, the mean length of stay for one-day surgery was 8.39 7.58 days, with a preoperative stay of 4.945.87 days, and postoperative stay of (3.454.38 days). b) Prospective review: Table 5 reviews the inappropriate hospitalization days as distributed by the subjects' age group and gender. It was indicated that both parameters (age and gender) had no statistical significance in relation to the inappropriate stay. Patients aged more than 60 years old stayed longer preoperatively (4.29 2.49). Moreover, males were found to stay longer pre and postoperative days than females.
Table 6 illustrates reasons of inappropriate longer hospital stay among patients scheduled for one-day surgeries. For long preoperative stay, it was found that in most cases, premature admission (71.21%) was the most frequent reason. However, patient's stay to carry out diagnostic procedures and/or treatment revealed the highest frequency of inappropriateness reasons (75.48%), followed by lack of family for home care (15.87%).
Discussion: The study was primarily conducted to assess the rate of inappropriate hospitalization days among one-day urology surgery patients. The rate of inappropriate patient days in the current study is quite significant higher as compared with the rates found in other studies conducted in different countries etal
(20)
and others
(21-22, 30)
(20-29)
. Parallel with the results of the present study, Anton
found that surgical specialty units usually have higher numbers
of unnecessary hospital days. Inappropriate days of hospitalization, in a tertiary care specialty unit, equipped with highly trained health care providers and administrators, and conducting much of its procedures classified as one-day surgery can be explained by prolonged premature admission of interesting cases for teaching activities
(8)
, as well as
special services that may be required on admission before any surgical intervention. This 5
justification was advanced by Chakravarty etal.(20), and Teke etal
(28)
. Moreover, the
hospital receives patients from peripheral hospitals and care settings, which may not have adequate investigation facilities and thus, these patients need substantial workup before any definitive management. In addition, concerns for returning the healed patient to his unit may influence the physician to retain him for few days –rather than hours- for complete recovery. These justifications were highlighted in Celik etal (24) in a case study conducted in a University Hospital in Turkey. It was advanced that inappropriate post-minor surgery stay was due to surgeon’s fears from the home environment, particularly in rural areas where necessary care during the period of recovery or timely medical aid in an emergency would not be ensured. This factor might have influenced the urology surgery specialists to retain the patients for evaluation and monitoring
(21)
, or conducting diagnostic procedures and/or
treatments that could have been carried out on an ambulatory basis
(27)
. Reasons for long
inappropriate stay indicated that admission on a weekend and/or surgeon's operative schedule, as well as follow up procedures as causes for prolonged one-day surgery stay and are indicative of lack of organizational resource misutilization (22).
Conclusion: In conclusion, the study documented a substantial proportion of inappropriate hospital use under the current system of hospital services. On the other hand, the most frequent causes for inappropriate hospitalization were premature admissions, weekend inclusion, and problems in scheduling surgery, for the preoperative period, and doing diagnostic procedures and/or treatment that can be done on an outpatient basis, as well as lack of family for home care, for the post-operative period.
Recommendations: Several admissions to Urology Surgery Department can be managed as one-day surgeries, which are expected not to stay more than a day. Moreover, applying such system needs multidisciplinary collaboration to change in the physicians’ behavior for more efficient utilization of hospital resources. Additionally, strategic changes are required in the organization of unit routine activities and utilization management, which may be effective in improving the quality and efficiency of provided care. Furthermore, there is a need for regular reviews as a part of internal audit of in-service hospital to conserve scarce health care resources of university hospitals.
6
Further Studies: Further studies are required in different specialties and general medical and surgical wards to assess the rate of appropriateness/inappropriateness of hospital admissions and days, as well as the reasons and delay factors for each inappropriate admission and/or hospitalization day.
Table (1): One-day Urology surgical procedures recommended by surgeons.
Urology surgical procedures Bladder biopsy Bladder instillation chemotherapeutics Circumcision Cystoscopy Cystolithotripsy Dilatation of the bladder neck, urethral meatus Dorsal slit in phymosis Extracorporeal Stock Waves Lithotripsy (ESWL). Epididymectomy Hydrocelectomy Meatotomy Nephrostomy tube insertion Orchidectomy Orchiopexy Penile prosthesis insertion, revision, replacement Prostate biopsy Testicular biopsy Trans- urethral resection of bladder tumor (TURBT) Trans- urethral resection of bladder neck Trans- urethral resection of prostate(TURP) Ureteroscopy/ stone removal Urethral dilatation Varicocelectomy
Response Frequency (n=24) 19 21 23 23 20 21 21 24 22 23 23 24 24 23 23 24 24 22 22 22 23 23 24
% 79.17 87.5 95.83 95.83 83.33 87.5 87.5 100 91.67 95.83 95.83 100 100 95.83 95.83 100 100 91.67 91.67 91.67 95.83 95.83 100
7
Table (2): Characteristics of the patients admitted to urology surgery department in year 2004:
Characteristics Age in years: < 10 10 < 20 < 30 < 40 < 50 < 60 Gender: Male Female Type of admission: Out patient clinic. Emergency dept. Intervention: One-day surgery Multi-days surgery
Non-operated cases.
Frequency (n = 1607)
Percent (%)
207 116 220 185 292 282 305
12.9 7.2 13.7 11.5 18.2 17.5 19.0
1195 412
74.4 25.6
1492 115
92.8 7.2
800 435
49.8 27.1
372
23.1
Table (3) distribution of subjects according to their age, gender and intervention "Retrospective audit". Subjects Characteristics
One-day n=800 %
Intervention Multi days Miscellaneous Total n=435 % n=372 % n=1607 %
Significance
1. Gender: - Male:
629
78.6
297
68.3
269
72.3
1195
74.4 X2=16.898*
- Female: 2. Mean Age & SD:
171
21.4
42.12 20.76
138
31.7
38.35 18.77
103
27.7
32.8922.66
412
25.6
38.9621.02 F = 25.512*
* P < 0.001
8
Table (4): Distribution of subjects' hospital days according to the intervention, for the year 2004. Duration of Hospital Stay (days)
One day (n=800) %#
Intervention Multi days Others (n=435) %# (n=372) %#
Total (n=1607) %#
Significance
1. Preoperative days: Number 3953 % 21.60 X SD 4.94 5.87
4257 23.26 9.79 8.25
----
8210 44.85 6.65 7.18
t-test = 10.84*
2. Postoperative days: Number 2762 % 15.09 X SD 3.45 4.38
3464 18.92 7.96 6.61
----
6226 34.01 5.04 5.70
t-test = 12.79*
8156 44.56
2634 14.39
18305 100.0 10.62 9.65
F = 207.19*
3. Total LOS: Number % X SD
7515 41.05 8.39 7.58
17.75 10.95
7.08 7.54
#
Percent is out of the grand total (18305) Length of Stay, Includes the operative days when applicable. * P ≤ 0.001
Table (5): Distribution of subjects' inappropriate hospitalization days according to their age group and gender "Prospective audit 2005".
Inappropriate Hospitalization Days Characteristics of subjects
1. Age: - < 60 (n=76) 60 + (n=24) Mann Whitney Z (P)* 2. Gender: - Male. (n=95) - Female. (n= 5) Mann Whitney Z (P)*
Preop. X SD
Postop. X SD
Total LOS X SD
3.90 2.18 4.29 2.49 0.878 (0.3801)
2.11 1.16 1.92 0.72 0.564 (0.5730)
6.00 2.67 6.21 2.77 0.558 (0.5770)
4.07 2.28 2.40 0.55 1.931 (0.0535)
2.08 1.05 1.60 1.52 0.502 (0.6157)
6.16 2.83 4.00 2.00 1.623 (0.1045)
* P < 0.05
Length Of Stay.
9
Table (6): Frequency Distribution of reasons of inappropriate longer hospital stay among patients scheduled for one-day surgeries "Prospective audit 2005". Reasons of Inappropriate long stay I. Preoperative: 1. Problem in scheduling surgery. 2. Problem in scheduling diagnostic procedure. 3. Premature admission. 4. Patient dropped from the schedule for any reason. 5. A weekend. 6. Results of diagnostic tests/procedures or consultation not yet received. 7. Doing follow-up procedures and/or treatment that can be done on an outpatient basis. Sub-Total II. Postoperative: 1. A weekend. 2. Doing follow-up procedures and/or treatment that can be done on an outpatient basis. 3. Discharge planned, but no orders written. 4. Lack of family for home care. Sub-Total Total
Frequency
Percent
34 2 277
8.74 0.51 71.21
18
4.63
44
11.31
10
2.57
4
1.03
389
65.16
4
1.92
157
75.48
14 33 208
6.73 15.87 34.84
597
100
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