Barriers to same-day discharge after percutaneous nephrolithotomy

Introduction & Objective: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. Methods: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed issues and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. Results: Excessive pain was the most common postoperative issue (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. Conclusions: Pain is the major barrier to same-day discharge after PCNL. Bleeding is infrequent and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.

Transforming the Urology clinic to a procedure-oriented center improves the quality of urological care and patient experience

Introduction & Objective: The global pandemic of COVID 19 necessitated limitations for in-person visits to stop the spread of the virus. At our institution, we sought to maintain patient access while delivering safe socially distanced care. We hypothesized that transitioning the clinics into a procedure-oriented center would create a safer, more efficient model for patient care delivery. Methods: Transitioning the clinic consisted of adopting Telehealth visits for the majority of patient's consultations while augmenting the use of physical space in the clinic to facilitate urological procedures. Multiple productivity, financial and patients experience metrics were collected between two periods of time defined as P1- Pre Covid (Feb-Jun 2019) and P2 Post-Covid (Feb-Jun 2020) and compared. Statistical analysis was performed using the Chi-Square test and the Z-test for two independent samples. Results: The percentage of performed procedures amongst all clinical visits increased in P2 (45% vs 29% p < 0.001). There was an increase in the percentage of new patients scheduled within 5- and 14-days during P2 (71 % vs 46%, p < 0.001, and 55 % vs 41%, p < 0.001) respectively. Total charges and RVUs decreased in P2 but the overall payments were higher compared to P1. This increase in revenue was due to a higher income generated by procedures. CGCAHPS and Press Ganey scores improved in P2 across all domains representing patient experience. This improvement was statistically significant for “Recommend this provider office” (90% vs 85.7% p = 0.01), “Access overall” (56% vs 49% p = 0.02), and “Moving through your visit overall” (59% vs 51% p = 0.007). Conclusions: Our data suggests that transitioning the urology clinics into a space that is mainly dedicated to outpatient procedures can represent a model that improves the patient's access to care and clinical experience, as well as strategically bolstering financial revenues. This is a more efficient care model that could replace current practice and represent the future of outpatient Urology. (Table Presented).

Pain is the most common clinical barrier to same-day discharge after percutaneous nephrolithotomy

INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. METHODS: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed clinical problems and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. RESULTS: Excessive pain was the most common postoperative problem (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. CONCLUSIONS: Excessive pain is the most common clinical barrier to same-day discharge after PCNL and affects nearly half of all patients. Bleeding is infrequent, and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.