Early Discharge After Abdominal Surgery
December 1, 1999 3 minutes read
Early Discharge After Abdominal Surgery
Abstract & commentary
Synopsis: Early hospital discharge following gynecologic surgery does not lead to significant complications.
Source: Rardin CR, et al. Gynecol Oncol 1999;75: 47-50.
Despite the fact that managed care organizations have placed great pressure on physicians to discharge patients from the hospital early after surgical procedures, few studies have examined the effect of such mandated early discharges. In fact, there are virtually no data in the literature to support the use of prolonged hospital stays following gynecologic surgery prior to the imposition of cost-contained measures.
Rardin and colleagues implemented aggressive, standardized practices for the early dismissal of patients from the gynecologic oncology service, and reported the results of this practice for the 266 consecutive patients who were discharged from the service between December 1994 and June 1996. All patients on the service were included in the study with no exclusions. The patients ranged in age from 18 years to 96 years, and greater than half had malignant disease.
Rardin et al identified 19 demographic, clinical, and surgical variables that they believed might affect length of stay and readmission. These included such things as type of incision, diagnosis (22% had ovarian cancer), ASA Class (only 30% were Class 1), prior laparotomy (36%), major adhesions (23%), lymph node sampling (21%), use of prophylactic antibodies and analgesics, time of oral feeding, etc. The mean length of stay for all patients was 2.94 days.
After multivariate analysis, only three variables predicted the need for a prolonged hospital stay—coronary artery disease, type of surgical procedure, and bowel surgery. Patients with radical hysterectomy, and those who underwent extensive debulking procedures required extended hospital stays. There were no patient deaths during hospitalization or during the next 30 days. Seven patients (2.6%) were readmitted during the first month following discharge. Four of these seven had developed wound cellulitis.
In the discussion section, Rardin et al identified "key points" that they believe are necessary to develop a short-stay postsurgical program. These include preoperative patient counseling, early ambulation, and early oral intake. Rardin et al point out that, despite the fact that it has been common practice in the United States to withhold oral feeding until the patient exhibits bowel sounds or passage of flatus, "There are no data to support this practice, in fact, recent studies suggest that some patients undergoing major bowel resections may be fed immediately."
Comment by Kenneth L. Noller, MD
This article represents another in a growing list of papers that support the early discharge of patients following major abdominal surgery. While all papers agree that exceptions to short stay are appropriate (e.g., patients with other serious medical diseases, intraoperative complications, general debilitation, etc.), the vast majority of patients may be discharged safely far sooner than was done in the past.
I have been following this growing body of literature closely during the past several years. Despite my preconceived ideas, it has become clear that early discharge is both safe and readily accepted by patients. Indeed, most patients in general good health prefer to be at home rather than in the hospital during the postoperative recovery period.
All of the articles agree that there is one key piece that is essential to early discharge following abdominal surgery: early oral feeding. Indeed, it appears that the practice of waiting for audible bowel sounds prior to initiating oral feedings might, in the future, be looked upon as one of the great mistakes of the second half of the 20th century. The practice does not prevent the occurrence of ileus, causes patients to remain hungry and underfed for long periods of time, and adds significantly to hospital stay. Perhaps it is time to ban stethoscopes from the postoperative ward.
In the article by Rardin et al concerning early discharge, the following variables were found to be associated with prolonged hospitalization after abdominal surgery except:
a. coronary artery disease.
b. surgical procedure.
c. patient age.
d. bowel surgery.
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