ABSTRACT
INTRODUCTION: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to constraints of the COVID-19 pandemic. This study aims to identify the patient cost, institutional charges, net margin revenue, and contribution margins associated with SDD, and analyze financial benefits when compared with admission. METHOD(S): Retrospective review of colectomy performed at a single institution over a 2-year period assessed for clinical outcomes, cost, charges, and revenue. The data was divided between 2 populations, SDD and postoperative day 1 (POD1) discharge. In addition to financial data, other outcomes included readmission, complication, and operative time. RESULT(S): There was a statistically significant difference favoring SDD over POD1 discharge in average: operating time (p = 0.00036), direct cost (p = 0.00000001), and charges (p = 0.00007711). SDD average patient cost were $9,186 USD compared with $11,698 USD for POD 1, and average hospital charges for SDD were $84,038 vs $97,566 for POD 1. Average net revenue was expectedly lower in SDD, $21,471, when compared with POD1, $26,719, however when comparing contribution margins (SDD $12,285 v POD1 $15,021), there was no statistically significant difference, p = 0.212. There were no statistically significant differences in readmission or operative complication between populations. CONCLUSION(S): Amidst pandemic-related resource constraints, we found that SDD was associated with lower patient cost and comparable contribution margin, without a significant difference in readmission and operative complication when compared with POD1 discharge.
ABSTRACT
Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.