Focusing on shortening patients’ length of stay (LOS) following surgery may result in increased rates of post-discharge complications, according to a new study.
“LOS has been used as a meaningful outcomes measure and as a potential target for quality improvement,” said Roujia D. Li, MD, of Northwestern University Surgical Outcomes and Quality Improvement Center, in Evanston, Ill. “One way is by introducing accelerated pathways to decrease LOS, such as an enhanced recovery protocol.”
However, Dr. Li questioned whether a push toward shorter LOS has resulted in shifting complications to the post-discharge setting.
To answer this question, Dr. Li and her colleagues set out to characterize changes in LOS and post-discharge complications over time, and to evaluate risk factors associated with post-discharge complications.
Using data from the ACS National Surgical Quality Improvement Program (or NSQIP) Procedure-Targeted database, patients were identified who underwent colorectal, esophageal, hepato-pancreatico-biliary, gynecologic and urologic surgery from 2014 to 2019.
Among a total of 538,712 patients, median LOS decreased from three days in 2014 to two days in 2019. Additionally, overall postoperative complications, readmission rates, median LOS and mortality rates all decreased with time.
In contrast, while rates of postoperative complications often fell, those for post-discharge complications did not. The proportion of post-discharge complications—including surgical site infection/wound dehiscence, infections such as pneumonia, urinary tract infection, sepsis, cardiovascular complications and venous thromboembolism—increased from 44.6% in 2014 to 56.5% during 2019.
Patient characteristics associated with post-discharge complications included age, race/ethnicity, American Society of Anesthesiologists physical status class, functional status, body mass index and other comorbidities.
“It is crucial to develop a patient monitoring program to focus on the early identification and management of post-discharge complications,” Dr. Li said.
This article is from the December 2021 print issue.
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You cannot discharge someone and see them 2 weeks later in the office. Seeing them 24 to 72 hours after surgery does several things to prevent medical and social complications. You actually get to see the patient. The patient has to get out of bed (many patients come in their pajamas). You get to talk to the family and patient in private. You get to review the pathology report with patients and family members. You can personally give them a copy of the report (saves many phone calls with other family members). The patient will understand more not being on full dose narcotics. If there are compolications, you get a chance to "nip it in the bud",
“LOS has been used as a meaningful outcomes measure and as a potential target for quality improvement,”
No, actually LOS has only ever been "useful" as a target for cutting costs, making politicians and bean counters happy at the expense of patient welfare and physician anxiety. Though the damage, both physical and emotional, done by pressure for early discharge can be somewhat mitigated by efforts to follow the patient frequently and closely after discharge, it is simply dishonest to pretend that shorter LOS is anything but deleterious to patient health.