Fighting the obesity pandemic during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created delays in surgical care. The population with obesity has a high risk of death from COVID-19. Prior literature shows the most effective way to combat obesity is by weight loss surgery. At different times throughout the COVID-19 pandemic, elective inpatient surgeries have been halted due to bed availability. Recognizing that major complications following bariatric surgery are extremely low (bleeding 0-4%, anastomotic leaks 0.8%), we felt outpatient bariatric surgery would be safe for low-risk patients. Complications such as DVT, PE, infection, and anastomotic leaks typically present after 7 days postoperatively, well outside the usual length of stay. Bleeding events, severe postoperative nausea, and dehydration typically occur in the first few days postoperatively. We designed a pathway focused on detecting and preventing these early post-op complications to allow safe outpatient bariatric surgery. METHODS: We used a preoperative evaluation tool to risk stratify bariatric patients. During a 16-month period, 89 patients were identified as low risk for outpatient surgery. We designed a postoperative protocol that included IV hydration and PO intake goals to meet a safe discharge. We sent patients home with a pulse oximeter and had them self-monitor their pulse and oxygen saturation. We called all patients at 10 pm for a postoperative assessment and report of their vitals. Patients returned to clinic the following day and were seen by a provider, received IV hydration, and labs were drawn. RESULTS: 80 of 89 patients (89.8%) were successfully discharged on POD 0. 3 patients were readmitted within 30 days. We had zero deaths in our study cohort and no morbidity that would have been prevented with postoperative admission. CONCLUSION: We demonstrate that by identifying low-risk patients for outpatient bariatric surgery and by implementing remote monitoring of vitals early outpatient follow-up, we were able to safely perform outpatient bariatric surgery.

Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass in Patients with Well-Regulated Obstructive Sleep Apnea.

INTRODUCTION: Same-day discharge after bariatric surgery is increasingly being performed. In current practice, patients with only minor comorbidities are considered eligible for same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB). Obstructive sleep apnea (OSA) is a common comorbidity in patients with morbid obesity, with a prevalence of around 70-80% among patients undergoing bariatric surgery. Continuous positive airway pressure (CPAP) is the current gold standard treatment for OSA. We aimed to investigate whether same-day discharge after RYGB is feasible for patients with compliant use of CPAP. METHODS: In this single-center prospective feasibility study, patients were selected who were scheduled for RYGB and were adequately treated for OSA. Compliance on the use of CPAP had to be proved (> 4 h per night for 14 consecutive nights). There were strict criteria on approval upon same-day discharge. The primary outcome was the rate of successful same-day discharge. Secondary outcomes included short-term complications, emergency department presentations, readmissions, and mortality. RESULTS: Forty-nine patients underwent RYGB with intended same-day discharge, of whom 45 (92%) were successfully discharged. Three patients had an overnight stay because of divergent vital signs and one patient due to a delayed start of the surgery. Two patients (4%) were readmitted in the first 48 h postoperatively, both due to intraluminal bleeding which was managed conservatively (Clavien-Dindo 2). There were no severe complications in the first 48 h after surgery. CONCLUSION: Same-day discharge after RYGB can be considered feasible for selected patients with well-regulated OSA.

Identifying Risk Factors for Complication and Readmission with Same-Day Discharge Arthroplasty.

BACKGROUND: The COVID-19 pandemic caused a surge of same-day discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary as well as risk stratification for improved patient outcomes. METHODS: This retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. RESULTS: SDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complications (AOR: 0.998, CI: 0.997-1.000). Patients who have preoperative dyspnea (AOR: 1.03, CI: 1.02-1.04, P < .001), chronic obstructive pulmonary disease (AOR: 1.02, CI: 1.01-1.03, P = .002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, P < .001), had higher odds of postoperative complications. Patients who had preoperative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, P = .003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, P < .001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, P < .001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, P = .038), had higher odds of readmission. CONCLUSION: SDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (eg, dyspnea, hypertension, and chronic obstructive pulmonary disease), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.

An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused major transitions in total joint arthroplasty (TJA), notably with the increased utilization of same-day discharge (SDD) pathways. This study assessed the effect of accelerated discharge pathways following the resumption of elective cases during the COVID-19 pandemic on SDD rates, adverse events, and characteristics associated with successful SDD following total hip and total knee arthroplasty. Methods: This retrospective study split patients into cohorts: TJA prior to COVID-19 (pre-COVID, July 2019-December 2019) and TJA following the resumption of elective surgeries (post-COVID, July 2020-December 2020). Patient characteristics such as age, sex, body mass index, American Society of Anesthesiologists score, and pertinent comorbidities were analyzed, and length of stay, 30-day emergency department (ED) visit rates, readmissions, and reoperations were compared. Results: A total of 1333 patients met inclusion criteria that were divided into pre-COVID (692) and post-COVID (641) cohorts. The pre-COVID group had a median age of 69 years (interquartile range 63-76), and the post-COVID group had a median age of 68 years (interquartile range 61-75) (P = .024). SDD increased from 0.1% to 28.9% (P < .001), and length of stay decreased from 1.3 days to 0.89 days (P < .001). There was no change in 30-day ED visits, readmissions, or reoperations (P = .817, P = .470, and P = .643, respectively). There was no difference in ED visits, readmissions, or reoperations in SDD patients. The odds of SDD were associated with age (P < .001, odds ratio [OR] = 0.94), body mass index (P = .006, OR = 0.95), male sex (P < .001, OR = 1.83), and history of tobacco use (P < .001, OR = 1.87). Conclusions: At our institution, the COVID-19 pandemic accelerated the utilization of SDD pathways without increasing ED visits, readmissions, or reoperations.

Bariatric surgeon perceptions of the safety of same-day sleeve gastrectomy in the state of Massachusetts.

BACKGROUND: During the past 2.5 years, select bariatric surgeons in the Commonwealth of Massachusetts have been implementing same-day sleeve gastrectomy (SDSG). Key reasons for this change have been to reduce risks associated with hospitalization in the context of the COVID-19 pandemic and to comply with third-party payer preference to reduce costs. OBJECTIVE: We aimed to evaluate bariatric surgeons' attitudes about outcomes and morbidity between patients who are hospitalized after sleeve gastrectomy and patients who undergo SDSG. SETTING: Beth Israel Deaconess Medical Center in Boston, Massachusetts (teaching hospital of Harvard Medical School). METHODS: This prospective cohort study was conducted among bariatric surgeons practicing in the Commonwealth of Massachusetts. An anonymous web-based questionnaire was distributed using the Research Electronic Data Capture software. A total of 58 bariatric surgeons in Massachusetts were identified and successfully contacted based on registration with the Massachusetts Board of Registration in Medicine, membership in the American Society for Metabolic and Bariatric Surgery, and internet search. RESULTS: A total of 33 bariatric surgeons in Massachusetts completed the survey, yielding a response rate of 56.9%. Among the respondents, 75.76% have not performed SDSG, reporting patient safety as the major concern, and 24.24% had performed SDSG in the past. CONCLUSION: Survey responses showed no significant differences in surgeon perception between SDSG and hospitalization after surgery. Optimal patient selection was an important factor influencing surgeons' decisions with regard to performing SDSG. However, bariatric surgeons in Massachusetts are reluctant to perform SDSG.

Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Cohort of 500 Consecutive Patients.

INTRODUCTION: There is an increasing demand on hospital capacity worldwide due to the COVID-19 pandemic and local staff shortages. Novel care pathways have to be developed in order to keep bariatric and metabolic surgery maintainable. Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is proved to be feasible and could potentially solve this challenge. The aim of this study was to investigate whether SDD after RYGB is safe for a selected group of patients. METHODS: In this single-center cohort study, low-risk patients were selected for primary RYGB with intended same-day discharge with remote monitoring. All patients were operated according to ERAS protocol. There were strict criteria on approval upon same-day discharge. It was demanded that patients should contact the hospital in case of any signs of complications. Primary outcome was the rate of successful same-day discharge without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality. RESULTS: Five hundred patients underwent RYGB with intended SDD, of whom 465 (93.0%) were successfully discharged. Twenty-one patients (4.5%) were readmitted in the first 48 h postoperatively. None of these patients had a severe bleeding. This results in a success rate of 88.8% of SDD without readmission within 48 h. CONCLUSIONS: Same-day discharge after RYGB is safe, provided that patients are carefully selected and strict discharge criteria are used. It is an effective care pathway to reduce the burden on hospital capacity.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation.

BACKGROUND: As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. METHODS: Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes. RESULTS: Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing. CONCLUSIONS: The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

Improved Rates of Same-day Discharge in Patients Undergoing Surgery for Endometrial Cancer Following the COVID-19 Pandemic.

STUDY OBJECTIVE: To determine the effect of the coronavirus disease 2019 (COVID-19) pandemic on the rate of same-day discharge (SDD) after minimally invasive surgery for endometrial cancer. DESIGN: Retrospective cohort. SETTING: Teaching hospital. PATIENTS: A total of 166 patients underwent a minimally invasive surgery procedure for the indication of endometrial cancer at a large academic institution from September 1, 2019, to October 1, 2020-80 patients before the implementation of the COVID-19 restrictions and 86 patients after. INTERVENTIONS: COVID-19 pandemic with visitor restrictions and hospital policy changes placed on March 17, 2020. MEASUREMENTS AND MAIN RESULTS: SDD rate was increased by 18% after the start of the COVID-19 pandemic (40% vs 58%, p = .02). There were no differences between the 2 groups with regard to operative time (p = .07), estimated blood loss (p = .21), uterine weight (p = .12), age (p = .06), body mass index (p = .42), or surgery start time (p = .15). In a multivariable logistic regression model, subjects in the COVID-19 group had 3.08 times (95% confidence interval, 1.40-6.74; p = .01) higher odds of SDD than those in the pre-COVID-19 group. There was no difference in 30-day readmission rates (7.5% vs 5.8%, p = .66). CONCLUSION: There was a significant increase in the SDD of patients with endometrial cancer since the start of the COVID-19 pandemic. The pandemic has strained hospital resources and motivated patients and physicians to avoid hospitalization. This shows that with proper motivation, an increase in SDD rates is possible without an increase in complications or rehospitalization.

Same-Day Discharge after Laparoscopic Appendectomy for Simple Appendicitis in Pediatric Patients-Is It Possible?

(1) Background: One-day surgery has been widely adopted for many elective laparoscopic procedures in pediatric patients. Recently, the same protocol has been investigated for some emergency procedures, such as laparoscopic appendectomy. This study aimed to evaluate the safety and effectiveness of discharge from hospital within 24 h in pediatric patients who received laparoscopic appendectomy for uncomplicated acute appendicitis. (2) Methods: From 1 March 2021 to 1 May 2022, a total of 180 pediatric patients who were discharged from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis were included in this prospective single-center study. The primary outcome of this study was the safety of discharge from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis, as well as the parental satisfaction with this protocol. Secondary outcomes included the rate of readmission or unplanned return to the operating room, the complication rate and a cost-effectiveness analysis. For each patient, demographic data, preoperative evaluation (physical examination, laboratory data, imaging), duration of surgery, intraoperative and postoperative complications, length of hospital stay and pain levels, as well as parental satisfaction with this protocol, were recorded. (3) Results: The median age was 11 years (interquartile range (IQR) 10, 14). The majority of the patients (63.8%) were males. The median length of hospital stay after surgery was 15 h (IQR 12, 19). The highest level of satisfaction, at discharge, was recorded in most of the respondents (n = 155, 86.1%), while the remaining 25 (13.9%) expressed moderate levels of satisfaction. The median pain levels according to a visual analogue scale for all postoperative days were low (range 0-4). In four patients (2.2%), unplanned readmission before the seventh postoperative day because of postoperative intraabdominal abscess was recorded. All patients with abscess formation were treated conservatively. The majority of the parents (n = 175; 97.2%) expressed the highest level of satisfaction during the outpatient follow-up examination on the seventh postoperative day. (4) Conclusions: Same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way.

The combined effect of policy changes and the covid-19 pandemic on the same day discharge and complications following total hip arthroplasty: a nationwide analysis.

INTRODUCTION: As a result of the SARS-CoV-2 (COVID-19) pandemic in 2020, elective surgeries, including total joint arthroplasty (TJA), were suspended nationwide. Concurrent removal of total hip arthroplasty (THA) from the Medicare inpatient-only list posed challenges to the delivery of quality patient care with low payor cost. Therefore, the objective of this study was to compare temporal trends in patient demographics, case volumes, length of stay, and complications following elective THA in the years 2019 to 2020 in the United States. METHODS: The 2019 to 2020 ACS-NSQIP database was queried for elective THA patients. Patients Pre-COVID (2019 and 2020Q1) were compared with post-COVID (2020Q2-Q4). THA utilization, demographics, 30-day complications, and length of stay (LOS) were compared between years. Linear regression evaluated changes in case volumes over time with significance threshold of P < 0.05. RESULTS: A total of 77,797 patients underwent elective THA in 2019 (n = 43,667) and 2020 (n = 34,130), resulting in a 24.5% decline. Outpatient THA increased in 2020 (35.6%) vs. 2019 (5.7%) (P < 0.001). There was no significant difference in the volume of cases in 2019Q1 through 2019Q4 (P = 0.984). Elective THA volumes declined by 68.8% in 2020Q2, returned to pre-pandemic baseline in 2020Q3, before leveling off at 81.5% of baseline in Q4. Average LOS was significantly shorter in 2020 (1.55 days) vs. 2019 (1.78 days) (P < 0.001) and the proportion of same day discharge (SDD) increased quarterly from 2019 to 2020. There was no significant difference in the total complication rates in 2019 (6.6%) vs. 2020 (6.6%) (P = 0.831). DISCUSSION: Elective THA precipitously declined during the second quarter of 2020. The combined effect of policy changes and the COVID-19 pandemic resulted in a seven-fold increase in the number of surgeries performed in the outpatient setting in 2020. Rates of SDD doubled over the study period, despite no change in complication rates.

Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery.

BACKGROUND: Since its inception colectomy has routinely been performed in the inpatient setting. The advent of Enhanced Recovery After Surgery (ERAS) protocols has led improved outcomes, including decreased length of stay (LOS). These improvements have introduced the possibility of ambulatory colectomy. However, indications, protocols, and limitations of ambulatory colectomy have not been extensively explored. METHODS: We conducted a retrospective review on ambulatory colectomies performed between February 2019 and August 2021. Patients were candidates for same day discharge (SDD) if they met rigorous preoperative criteria. Following an uncomplicated operation, strict postoperative parameters were required for safe discharge. If the patient underwent SDD following their operation, they were monitored closely via telehealth visits and/or patient communication messages until their one-week postoperative visit. RESULTS: From our review, we identified sixty-nine (n = 69) patients who underwent SDD after colectomy. Of the 69, only one patient was readmitted after discharge (1.4%). All procedures were performed via a robotic-assisted approach (Da Vinci Xi). None of the patients underwent conversion to an open procedure. The most frequently performed procedures included: low anterior resection (LAR) (n = 32, 46.4%) and right hemicolectomy (n = 11, 15.9%). CONCLUSION: Through proper patient education and strictly defined communication between the patient care teams, safe and effective care in the setting of SDD after colectomy can be provided. With recent technological advancements, enhanced mechanisms for patient education throughout all phases, and emerging means of patient-physician communication, via the data included herein the opportunity for same day discharge (SDD) after colectomy is a feasible and safe management plan in the proper patient.

Same-Day Discharge Protocol for Robot-Assisted Radical Prostatectomy: Experience of a High-Volume Referral Center.

Objective: As the coronavirus disease 2019 (COVID-19) global pandemic continues, there is increased value in performing same-day discharge (SDD) protocols to minimize viral exposure and maintain the appropriate surgical treatment for oncologic patients. In this scenario, we performed a prospective analysis of outcomes of our patients undergoing SDD protocol after robot-assisted radical prostatectomy (RARP). Materials and Methods: The SDD criteria included patients with no intraoperative complications, stable postoperative hemoglobin levels (compared with preoperative values), stable vital signs, normal urine output, ambulation with assistance and independently without dizziness, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family confidence with SDD. Patients older than 70 years, concomitant general surgery operations, multiple comorbidities, and complex procedures such as salvage surgery were excluded from our protocol. Results: Of the 101 patients who met the criteria for SDD, 73 (72%) had an effective SDD. All SDF (same day discharge failure) patients were discharged one day after surgery. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF, respectively. Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%), drowsiness (7%), patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). There was no significant difference in readmission rates, complication rates, or postoperative pain scores between SDD and SDF patients. Conclusions: In our experience, SDD for patients undergoing RARP can be safely and feasibly incorporated into a clinical care pathway without increasing readmission rates. We were effective in 72% of cases because of coordinated care between anesthetics, nursing staff, and appropriate patient selection. We also believe that incorporating pre- and postoperative patient education and assurance is crucial to minimize their exposure to COVID-19 during the surgical treatment for prostate cancer.

The resiliency of elective total shoulder arthroplasty case volumes in the United States during the COVID-19 pandemic: a nationwide temporal trends analysis.

BACKGROUND: Total shoulder arthroplasty (TSA) is one of the fastest growing procedures in terms of volume performed in hospitals in the United States. In 2020, elective surgery was suspended nationwide as a result of the SARS-CoV-2 (COVID-19) pandemic, and the use trends in the wake of the pandemic have yet to be evaluated substantially. Nationwide case volume reduction for TSA is unknown; therefore, the aim of this study is to compare patient demographics, complications, and temporal trends in case volume of elective TSA in the calendar year 2019 (prepandemic) to 2020 in the United States. METHODS: Using a multicenter, nationwide representative sample from 2019 to 2020, a retrospective query was conducted for all patients undergoing elective TSA. Patients undergoing surgery pre-COVID (2019 and 2020 Q1) were compared to those during COVID (2020 Q2-Q4). Temporal trends in case volumes were compared between time frames. TSA use, patient demographics, complications, and length of stay were compared between years. Linear regression was used to evaluate for changes in the case volume over the study period. A statistical significance threshold of P <.05 was used. RESULTS: In total, 9667 patients underwent elective TSA in 2019 (n = 5342) and 2020 (n = 4325). The proportion of patients who underwent outpatient TSA in 2020 was significantly greater than the year prior (20.6% vs. 13.9%; P < .001). Overall, elective TSA case volume declined by 19.0% from 2019 to 2020. There was no significant difference in the volume of cases in 2019 Q1 (n = 1401) through 2020 Q1 (n = 1296) (P = .216). However, elective TSA volumes declined by 54.6% in 2020 Q2. Elective TSA case volumes recovered to prepandemic baseline in 2020 Q3 and 2020 Q4. The average length of stay was comparable in 2020 vs. 2019 (1.29 vs. 1.32 days; P = .371), with the proportion of same-day discharge increasing per quarter from 2019 to 2020 (from 11.8% to 26.8% of annual cases). There was no significant difference in the total complication rates in 2019 (4.6%) vs. 2020 (4.9%) (P = .441). CONCLUSION: Using a nationwide sample, elective TSA precipitously declined during the second quarter of 2020. Patient demographics of those undergoing elective TSA in 2020 were similar in comorbidity burden. A large proportion of surgeries were transitioned to the outpatient setting, with rates of same-day discharge doubling over the study period despite no change in overall complication rates.

Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic.

PURPOSE: Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage. METHODS: A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions. RESULTS: Thirty-seven patients met the highly selective eligibility criteria for "healthy patient, healthy anastomosis." SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores. CONCLUSIONS: In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.

Same day discharge after structural heart disease interventions in the era of the coronavirus-19 pandemic and beyond.

With recent advancements in imaging modalities and techniques and increased recognition of the long-term impact of several structural heart disease interventions, the number of procedures has significantly increased. With the increase in procedures, also comes an increase in cost. In view of this, efficient and cost-effective methods to facilitate and manage structural heart disease interventions are a necessity. Same-day discharge (SDD) after invasive cardiac procedures improves resource utilization and patient satisfaction. SDD in appropriately selected patients has become the standard of care for some invasive cardiac procedures such as percutaneous coronary interventions. This is not the case for the majority of structural heart procedures. With the coronavirus disease 2019 pandemic, safely reducing the duration of time spent within the hospital to prevent unnecessary exposure to pathogens has become a priority. In light of this, it is prudent to assess the feasibility of SDD in several structural heart procedures. In this review we highlight the feasibility of SDD in a carefully selected population, by reviewing and summarizing studies on SDD among patients undergoing left atrial appendage occlusion, patent foramen ovale/atrial septal defect closure, Mitra-clip, and trans-catheter aortic valve replacement procedures.

A comparison of patient same-day discharge selection after shoulder arthroplasty before and after the COVID-19 pandemic.

Background: Early discharge has been a target of cost control efforts, given the growing demand for joint replacement surgery. Select patients are given the choice for same-day discharge (SDD) or overnight stay after shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD after shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD. Methods: A retrospective continuous review was performed on 370 patients who underwent a primary anatomic (total shoulder arthroplasty) or reverse shoulder arthroplasty between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients after the start of the pandemic. April 1, 2020, was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer's exact were performed where appropriate. Results: The 2 groups were similar in age, body mass index, gender distribution, and Outpatient Arthroplasty Risk Assessment score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (P = .029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have an SDD (P < .001), with 85.4% (158/185) of patients being discharged the same day after COVID-19, compared with 34.6% (64/185) before COVID-19. Discharge disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared with 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the 2 groups. Conclusion: Our study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon's practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients after total shoulder arthroplasty and reverse shoulder arthroplasty. Level of evidence: Level III; Retrospective Comparative Study.

Same-day discharge cardiac cathteterizations and interventional procedures during covid-19 pandemic in 2021

Background: One-year analysis of same-day discharge (SDD) coronary catheterizations, interventions and device replacement procedures during the covid-19 pandemic at the Complex Cardiovascular Center of the University Hospital in Pilsen. Methods: In 2021, 53 to 87 patients were admitted monthly and 817 in total to the SDD specialized Radial Lounge at the Department of Cardiology. Coronary angiography (CAG) was performed in 729 patients and percutaneous coronary intervention (PCI) in 176 (24%). Fifty-five patients were admitted for permanent pacemaker exchange and in 33 of them an implantable cardioverter-defibrillator exchange. Results: Out of 729 transradial CAGs 621 were performed by using the conventional proximal radial approach and 108 (15%) via the distal radial approach, 90 % of all procedures (n = 655), were performed from the nondominant left hand. Only one asymptomatic postprocedural radial artery occlusion was diagnosed by the reverse Barbeau test on the wrist (1/729 = 0.1%). No other relevant complications occured. The distal radial approach was associated with a shorter compression with time in comparison to the proximal puncture site at the wrist – 75 ± 26 min vs. 92 ± 24 (p < 0.05) and there were only four superficial hematomas smaller than 2 cm. In the proximal radial approach subcutaneous hematomas also did not require any specific treatment. Of the total of 817 patients, 90% (n = 732) were discharged home on the same day of admission in the afternoon and none of them was readmitted within the next 24 hours. The remaining 10% of the patients (n = 85) were hospitalized after the procedure, mostly because of severe findings on the coronary arteries. Conclusions: Coronary catheterizations and interventions together with device replacement procedures in the SDD program at the University Hospital in Pilsen were associated with a one-year saving of more than 700 overnight stays, minimal complications, and 99.9% radial artery patency rate after transradial procedures. © 2022 SOLEN s.r.o.. All rights reserved.

Same-Day Discharge Post-Transcatheter Aortic Valve Replacement During the COVID-19 Pandemic: The Multicenter PROTECT TAVR Study.

OBJECTIVES: The aim of this study was to determine the safety and efficacy of same-day discharge (SDD) after transcatheter aortic valve replacement (TAVR) during the COVID-19 pandemic. BACKGROUND: The COVID-19 pandemic has placed significant stress on health care systems worldwide. SDD in highly selected TAVR patients can facilitate the provision of essential cardiovascular care while managing competing COVID-19 resource demands. METHODS: Patient selection for SDD was at the discretion of the local multidisciplinary heart team, across 7 international sites. The primary outcome was a composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new permanent pacemaker (PPM) implantation. RESULTS: From March 2020 to August 2021, 124 of 2,100 patients who underwent elective transfemoral TAVR were selected for SDD. The average age was 78.9 ± 7.8 years, the median Society of Thoracic Surgeons score was 2.4 (IQR: 1.4-4.2), and 32.3% (n = 40) had preexisting PPMs. There were no major vascular complications, strokes, or deaths during the index admission. One patient (0.8%) required PPM implantation for complete heart block and was discharged the same day. No patient required a PPM between discharge home and 30-day follow-up. The composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new PPM at 30 days occurred in 5.7% patients (n = 6 of 106). CONCLUSIONS: SDD post-TAVR is safe and feasible in selected patients at low risk for adverse clinical events postdischarge. This strategy may have a potential role in highly selected patients even when the COVID-19 pandemic abates.

COVID-19 as a Catalyst for Same-Day Discharge Total Shoulder Arthroplasty.

The COVID-19 pandemic caused major disruptions to the healthcare system, but its impact on the transition to same-day discharge shoulder arthroplasty remains unexplored. This study assessed the effect of COVID-19 on length of stay (LOS), same-day discharge rates, and other markers of resource use after elective total shoulder arthroplasty. A total of 508 consecutive patients undergoing elective primary total shoulder arthroplasty between 2019 and 2021 were identified and divided into 2 cohorts: "pre-COVID" (March 2019-March 2020; n = 263) and "post-COVID" (May 2020-March 2021; n = 245). No elective shoulder arthroplasties were performed at our practice between 18 March and 11 May 2020. Outcome measures included LOS, same-day discharge, discharge location, and 90-day emergency department (ED) visits, readmissions and reoperations. There were no significant differences in baseline preoperative patient characteristics. Shoulder arthroplasty performed post-COVID was associated with a shorter LOS (12 vs. 16 h, p = 0.017) and a higher rate of same-day discharge (87.3 vs. 79.1%, p = 0.013). The rate of discharge to skilled nursing facilities was similarly low between the groups (1.9 vs. 2.0%, p = 0.915). There was a significant reduction in the rate of 90-day ED visits post-COVID (7.4 vs. 13.3%, p = 0.029), while there were no differences in 90-day reoperation (2.0 vs. 1.5%, p = 0.745) or readmission rates (1.2 vs. 1.9%, p = 0.724). The COVID-19 pandemic seems to have accelerated the shift towards shorter stays and more same-day discharge shoulder arthroplasties, while reducing unexpected acute health needs (e.g., ED visits) without adversely affecting readmission and reoperation rates.

Same-day discharge after transcatheter mitral valve repair using MitraClip in a tertiary community hospital: a case series.

BACKGROUND: Due to the current Coronavirus Disease 2019 (COVID-19) pandemic, there is a realization for innovation in procedures and protocols to minimize hospital stay and at the same time ensure continued evidence-based treatment delivered to the patients. We present a same-day discharge protocol for transcatheter mitral valve repair (TMVR) using MitraClip under general anaesthesia in a six-patient case series. This protocol aims to reduce the length of hospital stay, thereby minimizing potential for nosocomial COVID-19 infections and to promote safe discharge with cautious follow-up. CASE SUMMARY: Six patients with severe symptomatic mitral valve (MV) regurgitation underwent successful transfemoral MV repair using standard procedures. Following repair, patients were monitored on telemetry in the recovery area for 3 h, ambulated to assess vascular access stability and underwent post-procedural transthoracic echocardiogram to assess for any pericardial effusion or post-procedural prosthetic mitral stenosis. CONCLUSION: Same-day discharge after TMVR is possible when done cautiously with close follow-up, can minimize hospital stay, improve resource utilization, and reduce risk of nosocomial COVID-19 infection.