Same-day Discharge after Appendectomy Results

in Cost Savings and Improved Efficiency

SANDRA M. FARACH, M.D., PAUL D. DANIELSON, M.D., N. ELIZABETH WALFORD, M.D.,
RICHARD P. HARMEL, JR., M.D., NICOLE M. CHANDLER, M.D.

From the Division of Pediatric Surgery, All Children’s Hospital/Johns Hopkins Medicine, St. Petersburg, Florida

Appendectomy incurs significant costs for the healthcare system. There is evidence that patients
can be safely discharged the same day after appendectomy. The purpose of this study was to
develop an evidence-based protocol for same-day discharge after appendectomy. A fast-track
surgery protocol was developed for same-day discharge after appendectomy. This was pro-
spectively applied to all patients presenting for appendectomy from July 2012 to June 2013.
Demographics, clinical measures, and outcomes were measured. Of 206 patients eligible for same-
day discharge, 185 (90%) were successfully discharged according to the protocol. The mean length
of stay after appendectomy was 3.1 6 1.4 hours. Protocol implementation reduced inpatient use
from 99 to 53 per cent. Patient transfers were reduced, resulting in 40 per cent fewer handoffs. The
decreased use of hospital resources resulted in a median reduction of hospital charges of $4111 per
patient. The complication rate for patients discharged the same day was 2.7 per cent. Appendec-
tomy for acute appendicitis or interval appendectomy can be performed safely as same-day sur-
gery. Implementation of this protocol resulted in optimization of resource use by reducing
inpatient admissions, decreasing handoffs, and reducing hospital costs.

most common urgent pediat-
A PPENDECTOMY IS THE
ric surgical procedure with approximately 71,000
cases performed per year in children younger than 15
years of age.1 A recent epidemiologic study in the
United States from 1993 to 2008 showed an incidence
of acute appendicitis to be 9.4 cases per 10,000 pa-
tients.2 This is a disease that incurs significant costs for
the healthcare system with an estimated $680 million
in hospital use charges annually.3
Although appendectomy is rarely an elective pro-
cedure, patients undergoing appendectomy for acute
appendicitis are commonly discharged from the hos-
pital within 24 hours. Same-day surgery has been
widely accepted for a number of surgical procedures in
the pediatric population, including circumcision, her-
nia repair, orchidopexy, and correction of hypospa-
dias.4 Prospective studies have shown that up to 80 per
cent of children may be successfully discharged on the
day of operation.5–8
The aim of this study was twofold. The first was
to develop an evidence-based protocol for same-day
Presented at the Annual Scientific Meeting and Postgraduate
Course Program, Southeastern Surgical Congress, Savannah, GA,
February 22–25, 2014.
Address correspondence and reprint requests to Sandra M.
Farach, M.D., All Children’s Hospital Outpatient Care Center, 601
5th Street South, Department 70-6600, 3rd Floor, St. Petersburg, FL
33701. E-mail: sandra.farach@allkids.org.
discharge after appendectomy for acute appendicitis
and interval appendectomy with emphasis on safety
and cost standards. The second was to study outcomes
after implementation and standardization of a fast-
track appendectomy protocol in a free-standing pedi-
atric hospital.
Methods
A literature search was performed to determine
evidence-based best practice for same-day surgical
management of acute appendicitis. A protocol for
fast-track appendectomy was developed and was pro-
spectively applied to all patients with acute appendi-
citis presenting for appendectomy during the study
period from July 2012 to June 2013 (Fig. 1). Patients
presenting for initial evaluation and those undergoing
interval appendectomy were considered for same-day
discharge. After obtaining Institutional Review Board
approval (IRB 13-0601), a retrospective review of the
prospectively collected data during the study period
was performed.
Inclusion/Exclusion Criteria
Inclusion criteria for enrollment included patients
younger than 21 years of age undergoing appendec-
tomy for a diagnosis of acute appendicitis or interval

787
788 THE AMERICAN SURGEON
appendectomy. Preoperative exclusion criteria included:
complex appendicitis treated medically, pre-existing
complex medical conditions not suitable for outpatient
surgery, inadvertent admission to the inpatient unit,
social indications, or late operation. Postoperative ex-
clusion criteria included intraoperative findings of
suppurative, gangrenous, or perforated appendicitis;
fever greater than 38°C; hemodynamic changes; in-
ability to void; poor oral intake; or inadequate pain
control. Patients who did not meet inclusion criteria or
were excluded were treated per the standard group
practice based on diagnosis and clinical status.
Surgical Details
Once the need for appendectomy was determined,
patients remained in the emergency center under ob-
servation status or were transferred to the preoperative
holding area, depending on the time of day. One of four
attending pediatric surgeons performed all appendec-
tomies on a rotating basis determined by call schedule
with the aid of a pediatric surgery Fellow or midlevel
provider. All patients received preoperative antibiotics.
Appendectomy was performed by an open, multiport
laparoscopic, or single-incision laparoscopic technique
based on surgeon preference. Our group has previously
described and published our operative approach.9, 10
Acute appendicitis was defined as appendiceal hyper-
emia, dilation, or inflammation without the presence
of fibrinous exudate, turbid peritoneal fluid, or
perforation.
Postoperative Details
After appendectomy, patients were transferred to the
postanesthesia care unit (PACU). Patients received
August 2014 Vol. 80
FIG. 1. The traditional and fast-track patient
flow pathway. (A) The traditional patient flow
through hospitalization with transfer to six dif-
ferent care areas and five patient handoffs. (B)
The fast-track patient flow with transfer to four
different care areas and three patient handoffs.
standard verbal and written instructions as well as
viewed an educational video before discharge. Patients
were discharged home without any antibiotics once
discharge criteria were met.
Admission to the inpatient ward occurred from the
PACU for the following reasons: the operation oc-
curred too late for discharge, discharge criteria were
not met (febrile, hemodynamic changes, unable to
tolerate liquids, inadequate pain control), or for social
reasons (family refusal, no transportation, home greater
than 30 minutes from a hospital). All patients were
contacted by a perioperative nurse by telephone within
24 hours of discharge and seen by one of the four pe-
diatric surgery attendings in the outpatient clinic two
weeks after surgery.
Analysis
Demographics and outcomes were measured for all
patients who underwent appendectomy during the
study period (Table 1). Postoperative length of stay
was defined as time of arrival to the PACU until the
time the patient was discharged from the hospital.
Numeric values were calculated as mean values with
a standard deviation. Continuous data were analyzed
using Student’s t test and significance was considered
at P < 0.05.
Results
A total of 349 children presented for appendectomy
during the study period from July 2012 to June 2013
(Fig. 2). The mean age for all patients was 11.5 ± 3.8
years with a range of 1.5 to 20.6 years. Preoperatively,
303 patients were classified as acute appendicitis or
No. 8 SAME-DAY DISCHARGE AFTER APPENDECTOMY ? Farach et al. 789

TABLE 1. Patient Demographics and Outcomes

Total No. of Patients Nonfast-track Pathway Fast-track Pathway P Value*
Number of patients 349 164 185
Male 208 (59.6%) 97 (59%) 111 (60%) 0.9131
Age, mean ± SD (range) (years) 11.5 ± 3.8 (1.5–20.6) 11.8 ± 4.1 (1.5–20.6) 11.3 ± 3.6 (3–18.9) 0.2154
Weight, mean ± SD (range) (kg) 45.9 ± 21 (11.7–124.4) 47.2 ± 22.3 (11.7–124.4) 44.7 ± 19.7 (15.3–112) 0.2688
WBC, mean ± SD (range) 14.9 ± 5 (2.4–30.7) 15.9 ± 4.9 (2.4–30.7) 13.9 ± 4.8 (2.9–28.3) 0.0002
CRP, mean ± SD (range) 5 ± 6.4 (0.05–33.7) 7.4 ± 7.8 (0.05–33.7) 2.6 ± 2.8 (0.2–20.7) 0.0001
OR time, mean ± SD 24.9 ± 9.6 (10–105) 25.7 ± 11.3 (10–105) 24.4 ± 7.7 (10–52) 0.2106
(range) (minutes)
Appendectomy type
Single-incision laparoscopy 160 (45.8%) 73 (44.5%) 87 (47%)
Multiport laparoscopy 105 (30.1%) 60 (36.6%) 45 (24.4%)
Open 84 (24.1%) 31 (18.9%) 53 (28.6%)
Intraoperative findings
Acute 195 (55.9%) 35 (21.3%) 160 (86.5%)
Interval 20 (5.7%) 0 20 (10.8%)
Suppurative/gangrenous 80 (22.9%) 77 (47%) 3 (1.6%)
Perforated 52 (14.9%) 52 (31.7%) 0
Normal 2 (0.6%) 0 2 (1.1%)
LOS, mean ± SD 32.7 ± 66.1 (1–749.6) 66.1 ± 84.8 (3.1–749.6) 3.1 ± 1.4 (1–11.1) 0.0001
(range) (hours)
Complications 23 (6.6%) 18 (11%) 5 (2.7%) 0.0021
Superficial wound infection 7 6 2
Intra-abdominal abscess 6 5 0
Ileus/bowel obstruction 7 5 2
Other 3 2 1
* P values compare nonfast-track pathway to fast-track pathway patients.
SD, standard deviation; WBC, white blood cell count; CRP, C-reactive protein; OR, operating room; LOS, length of stay from
postanesthesia care unit arrival to discharge.

interval appendectomy and were initiated on the fast-
track pathway. Intraoperatively, 206 (68%) were found
to have acute appendicitis or interval appendectomy
and continued on the protocol. A total of 185 patients
were discharged from the PACU after appendectomy,
which comprised 90 per cent of patients with acute
appendicitis.
The mean length of time to first oral intake was
51.7 ± 29.6 minutes. The mean number of parenteral
narcotic doses was 2 ± 1.4, and mean number of enteral
narcotic doses was 1 ± 0.4. The mean postoperative
length of stay for patients discharged from the PACU
was 3.1 ± 1.4 hours (range, 1 to 11.1 hours). The
complication rate for those patients who completed the
fast-track appendectomy protocol was 2.7 per cent
compared with 6.7 per cent for all patients with ap-
pendicitis over the study period. Complications for
those completing the protocol included two surgical
site infections treated with outpatient oral antibiotics,
one patient with ileus, one patient with small bowel
obstruction requiring exploratory laparotomy and lysis
of adhesions, and one patient with Henoch-Schönlein
purpura presenting with hematochezia, nephritis, and
Clostridium difficile infection.
Patients successfully discharged the same day did
not enter the inpatient facility, resulting in a decrease
in patient transfers from six to four and a 40 per cent
decrease in patient handoffs from five to three (Fig. 1).
This decrease in use of inpatient resources resulted in
a median reduction in hospital charges of $4111 per
patient discharged from the PACU after appendec-
tomy. This resulted in a total savings of $760,535
during the 1-year study period.
Discussion
The fast-track concept was first described by Henrik
Kehlet to optimize perioperative care in elective sur-
gery.11 Implementation of this concept encompasses
preoperative instruction, immediate postoperative
feeding and mobilization, preference of minimally
invasive techniques, and specific pain control tech-
niques.11, 12 In adults, fast-track surgery has been de-
scribed for a number of surgical procedures, some of
which include cholecystectomy, bariatric surgery, co-
lonic surgery, pulmonary resection, reflux surgery,
prostate surgery, adrenal surgery, breast surgery, and
thyroid and parathyroid surgery. Implementation has
been shown to significantly reduce length of stay and
reduce complication rates.13 In one prospective study,
80 per cent of pediatric patients were discharged after
laparoscopic appendectomy on the same day with
a mean postoperative length of stay of 4.8 hours with
no increase in complication or readmission rates. Of
patients with acute appendicitis, 55 per cent never
entered into the inpatient facility.7
790 THE AMERICAN SURGEON August 2014 Vol. 80

FIG. 2. The hierarchy and number of patients throughout the course of the fast-track protocol: patients included in the protocol,
patients excluded from the protocol, and indications for exclusion from the protocol.

Our experience is that 90 per cent of patients with
acute appendicitis can be safely discharged from the
PACU. The successful implementation of this protocol
centered on a multidisciplinary approach, which in-
volved members of the emergency medicine, anes-
thesia, surgery staff, and administration. There was
a focused awareness on changes in patient flow pro-
cess, handoffs, pain control measures, and discharge
education. Protocol implementation included detailed
preoperative, perioperative, postoperative, and follow-
up guidelines. Criteria were developed and clearly
defined to determine suitability for patient placement
in the protocol. The anesthesia model was changed
to replicate anesthesia given during ambulatory
procedures.
Standardized protocols such as this one impact the
delivery of care by decreasing handoffs, reducing in-
patient admission, standardizing communication, and
reducing length of stay. Traditionally, in our facility,
patients with acute appendicitis moved through six
different care locations resulting in five handoffs. The
Children’s Hospital Association states that one-third of
sentinel events are associated with handoff communi-
cation failures.14 This fast-track protocol reduced the
number of handoffs by 40 per cent, thus decreasing the
potential for medical errors.
No. 8 SAME-DAY DISCHARGE AFTER APPENDECTOMY
This protocol became the expected course at our
institution for children undergoing appendectomy for
acute appendicitis or interval appendectomy. Imple-
mentation of this protocol resulted in a postoperative
length of stay of three hours for patients completing
the fast-track pathway and led to a reduction in in-
patient use from 99 to 53 per cent for patients with
acute appendicitis. The decreased use of inpatient re-
sources realized a total savings of $760,535 per year
for our institution. Given that nearly 71,000 appen-
dectomies are performed yearly in children and 53 per
cent may be eligible for early discharge, this simple
approach could result in nearly $155 million cost
savings yearly.
Despite the current evidence to support the bene-
fits of fast-track surgery management, implementa-
tion into daily practice has been slow, and most
perioperative care is still traditional at many in-
stitutions.15 Adoption into routine clinical practice is
dependent on a multidisciplinary approach that in-
cludes education and organizational changes within
the hospital. There is a need for evidence-based
studies for the standardization of procedure-specific
and/or organ-specific fast-track protocols. The
implementation of such protocols has the poten-
tial for improving the quality and effectiveness of
health care.
Conclusion
Our institution was successful in creating a fast-
track appendectomy protocol for patients presenting
with acute appendicitis or interval appendectomy.
Implementation resulted in optimization of resource
use by reducing inpatient admission, decreasing the
number patient handoffs, and reducing hospital costs.
Appendectomy for acute appendicitis or interval ap-
pendectomy can be performed safely as same-day
surgery while improving quality of care. Significant
healthcare benefits may result with adopting the fast-
track protocol as the standard treatment for acute ap-
pendicitis in children.
? Farach et al. 791
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