Appropriateness of Length of Hospital Stay for Patients UndergoingOne-Day Urology Surgery Hanan A. Alkorashy†, El-Mahalli A A.‡, Hamdy S.M.N.¶ † Hanan A. Ezzat, Lecturer, Nursing Administration, Faculty of Nursing, Alexandria University. ‡ Azza El-Mahalli, Lecturer of Health Administration & Planning, High Institute of Public Health, Alexandria University. ¶ Saif Al-Eslam Mahmood Hamdy, Professor, Urology Surgery Dept., Faculty of Medicine, Alexandria University. Abstract: One day surgery has developed over the past 3 decades for a number of reasons including advanced managing care and health maintenance organizations, improved surgical instruments, less invasive surgical techniques, availability of a team approach in preparing a person for surgery and home recovery and the desire to reduce health care costs. The present study aimed at assessing the Pre-decided one day surgeries among patients admitted in urology surgery department at the Main University Hospital, determining proportion of inappropriate days of hospitalization, and uncovering reasons associated with inappropriate utilization of hospital stay. Among 1607 reviewed records, 800 (49.78%) cases were decided to be conducted as one-day surgeries. Concerning the total Length of Stay (LOS), findings revealed that only 10.6% of these days were appropriate89.4% of the reviewed hospital days were inappropriate and can be managed for more efficient and effective care provision. Premature admission, weekends and problems in scheduling surgery were the reasons of inappropriate preoperative stay, while doing diagnostic procedures and/or treatment that can be done on an outpatient basis and lack of family for home care, were found to be reasons for postoperative stay. Introduction: Surgical intervention is evolving and developing, giving a variety of operative options to the surgeon and to the patient. Many of the current innovations have contributed to one day surgery (1-4). It is also called ambulatory or outpatient surgery and it refers to any surgical procedure for which the patient is admitted and discharged on the same day. In the United States, more than 60% of elective surgeries are currently performed as one day surgeries. Health experts expect that this percentage will increase to nearly 75% over the next decade.(5) One day surgery has developed over the past 3 decades for a number of reasons including advanced managing care and health maintenance organizations,(6) improved surgical instruments, less invasive surgical techniques, availability of a team approach in preparing a person for surgery and home recovery health care costs. (7-9) (5) and the desire to reduce Recently, people with more complex medical problems are scheduled for one day surgery, and types and complexity of surgeries have expanded significantly.(5) Early discharge from hospital after surgery is safe and is well accepted by patients.(10-12) One day surgery seems to enhance the opportunity for social support within the family and may facilitate discussion of the illness with the family members,(2) recovery in the patient’s own environment results in better psychological adjustment as a result of enhanced patient 1 Subjects: Surgeons: Twenty four urology surgeons from urology department. faculty of medicine including professors. Methodology: Setting: The study was conducted at the medical record department and the urology surgery department. One-Day Surgery Opinnionnaire Sheet: was designed to reflect the surgeons' opinion regarding the surgical procedures which are to be performed in one-day basis.(6) or. long hospital stay is detrimental for patients as hospitals are not safe and patients are at risk for developing infections (15) . This may be an inappropriate over or under utilization of acute care resources when patients could be discharged home. assistant professors. as well as exposure to have a higher rate of unemployment. children benefit significantly from one day surgery as it decreases separation from their family and home.(13) Also. were involved in the study process. and better interaction with family members.comfort. 18). 2. Determine days of hospitalization among patients admitted for any of the recommended one-day surgeries scheduled in 2004. 2 . uses the doctor’s time more efficiently and does not increase the incidence of wound infection.(2) Moreover. at Alexandria Main University Hospital. Identify reasons associated with current inappropriate hospital stay for patients scheduled for any of recommended one-day surgeries.(14) One day surgery reduces medications prescribed. (9) On the other hand. assistant lecturers and residents conducting various types of urology surgeries participated in the study. Patients: One hundred patients admitted. lecturers. (16) The aim of the present study was to: 1. The list of surgeries was derived from the pertaining literature (17. independence. 3. long stay patients utilize a considerable proportion of inpatient hospital resources. control. having difficulty in re-entering the real world. Identify acceptable one-day surgeries for patients admitted in urology surgery department as recommended by surgeons. Tools: Three tools were used to collect data: 1. having bad reactions to medications. and scheduled for recommended oneday surgeries. as reflected in literature. and reasons of appropriateness and inappropriateness for each. The total number of records was 1607. and dates of admission. 2004. intervention. operation and discharge. gender. The surgical procedures were categorized as either of one-day or multi-days types. Method of data collection: After the official approvals were obtained. gender. was done over a period of two months. appropriateness of each hospitalization day. Data collected included patient's age. The Appropriateness of Hospital Stay Sheet was designed to identify the reasons of inappropriate hospitalization days among patients planned to do one-day surgical procedures. provisional and final diagnosis. Each day was assessed for its appropriateness/inappropriateness of stay in urology department. Twenty four faculty members responded. All medical records of the patients admitted to the urology surgery department through out the year 2004 were obtained and reviewed. b. date of the operation. Appropriateness of Hospital Stay Sheet: This tool was derived from Appropriateness Evaluation Protocol (AEP) (19) . final diagnosis. and scheduled for any of the recommended one-day surgeries. admission date and source. using the "Retrospective Surgery Review Sheet". in one-day surgery system in the study setting. Agreement of 70% or more of the participants was a criterion for considering the surgical procedure applicable to be conducted as a one-day surgery. 3 . Data included were patient's age. Reasons for inappropriateness either preoperatively or postoperatively were assessed for each inappropriate day. source of admission (OPC or RR). and reason(s) for inappropriate preoperative and postoperative hospital stay. 3. are appropriate or not. the urology surgeons were asked to complete the "One-Day Surgery Opinnionnaire". data were collected in two phases: a.2. Prospective Phase: Monitoring of 100 patients admitted to the department. and hospitalization days. Retrospective Surgery Review Sheet: was developed to gather the required information through auditing medical records over one year. Retrospective Review Phase: In order to examine the applicability of conducting the selected surgical procedures. Their records were being reviewed daily from the day of admission till discharge. The AEP is an international protocol intended to assess if the admission. date of discharge. Twenty three percent of subjects discharged without undergoing a surgical procedure.1%).1 % were admitted for multi-days surgeries.45%) and were mainly admitted to the unit through the outpatient clinic (92. either one-day surgery.8%). gender and type of intervention. Table 3 shows distribution of subjects according to their age. Prostate biopsy. while in relation to age. and 27. P < 0.898. preoperative stay was calculated by subtracting date of admission from the date of the operation. patients who were scheduled for one-day surgeries were significantly older than those scheduled for 4 . 78. For gender.Statistical Analysis: SPSS version 11. or follow-up. though they received medical treatment. whereas postoperative stay was calculated by subtracting preoperative stay from the LOS and average LOS was computed as total LOS divided on total discharges. adding days as necessary when the patient’s stay extends over one or more month endings. The LOS for each patient was determined by subtracting the date of admission from the date of discharge when the patient was admitted and discharged within one month. Results: a) Retrospective review: Table 1 illustrates the Urology surgical procedures recommended by surgeons to be regarded as one-day surgeries. investigations done and/or other diagnostic procedures (23.5 was used for data entry and analysis. and total Length of Stay (LOS) were calculated to determine inappropriate days. while Bladder biopsy was recommended by only 79. Majority of patients were males (74. The table indicates that the difference among the three interventions were statistically significant in both gender and age. Extracorporeal Stock Waves Lithotripsy and Varicocelectomy were recommended by all surgeons to be conducted as one-day procedure.05). It included those procedures reported by 70 % of the involved surgeons or more. Nephrostomy tube insertion. About half of the reviewed records were had belonged to patients scheduled for one-day surgery (49. diagnostic procedures. preoperative. Moreover.17% of the surgeons. or cases with no surgical intervention but stayed for receiving treatment. Testicular biopsy. multi-day surgery. In case of operative interventions. postoperative. It was found that more than 50% of the involved patients were aging more than 40 years old (19% were more than 60 years old). Orchidectomy. Table 2 illustrates Characteristics of the patients admitted to Urology Surgery Department in year 2004.6% of the patients scheduled for one-day surgeries were males (X2 = 16.8%). The retrospective Analysis focused on classifying patients according to intervention. longer stays. The rate of inappropriate patient days in the current study is quite significant higher as compared with the rates found in other studies conducted in different countries etal (20) and others (21-22. Anton found that surgical specialty units usually have higher numbers of unnecessary hospital days.29 2. and postoperative stay of (3. males were found to stay longer pre and postoperative days than females. 38. Inappropriate days of hospitalization. Moreover. Discussion: The study was primarily conducted to assess the rate of inappropriate hospitalization days among one-day urology surgery patients. Moreover.21%) was the most frequent reason. This 5 . premature admission (71.05% of the total length of stay for all subjects (18305 days). Parallel with the results of the present study. For long preoperative stay. P < 0. with a preoperative stay of 4.58 days. in a tertiary care specialty unit.87%). equipped with highly trained health care providers and administrators.49).39 7. followed by lack of family for home care (15. Patients aged more than 60 years old stayed longer preoperatively (4. It was indicated that both parameters (age and gender) had no statistical significance in relation to the inappropriate stay. for surgical procedures that should consume not more than one day of hospital stay.77 years. Table 6 illustrates reasons of inappropriate longer hospital stay among patients scheduled for one-day surgeries. 32. the mean length of stay for one-day surgery was 8. and conducting much of its procedures classified as one-day surgery can be explained by prolonged premature admission of interesting cases for teaching activities (8) . as well as special services that may be required on admission before any surgical intervention.512.87 days. 30) (20-29) .05).66 years) respectively. (X = 42. and that only 10.38 days). b) Prospective review: Table 5 reviews the inappropriate hospitalization days as distributed by the subjects' age group and gender.454.1220. it was found that in most cases.48%). However. patient's stay to carry out diagnostic procedures and/or treatment revealed the highest frequency of inappropriateness reasons (75.89±22. (F = 25.35±18.945. It indicated that the total length of hospital stay for reviewed subjects (7515 days) representing 41.65% of these days were appropriate. Table 4 shows the distribution of subjects' hospital days according to the intervention.76 years. Conclusion: In conclusion. and problems in scheduling surgery. as well as lack of family for home care. It was advanced that inappropriate post-minor surgery stay was due to surgeon’s fears from the home environment. and doing diagnostic procedures and/or treatment that can be done on an outpatient basis. Moreover. and Teke etal (28) . these patients need substantial workup before any definitive management.justification was advanced by Chakravarty etal. In addition. the hospital receives patients from peripheral hospitals and care settings. for the preoperative period. strategic changes are required in the organization of unit routine activities and utilization management. as well as follow up procedures as causes for prolonged one-day surgery stay and are indicative of lack of organizational resource misutilization (22). This factor might have influenced the urology surgery specialists to retain the patients for evaluation and monitoring (21) . the study documented a substantial proportion of inappropriate hospital use under the current system of hospital services. or conducting diagnostic procedures and/or treatments that could have been carried out on an ambulatory basis (27) . particularly in rural areas where necessary care during the period of recovery or timely medical aid in an emergency would not be ensured. Additionally. Furthermore. Moreover. applying such system needs multidisciplinary collaboration to change in the physicians’ behavior for more efficient utilization of hospital resources. which may not have adequate investigation facilities and thus. These justifications were highlighted in Celik etal (24) in a case study conducted in a University Hospital in Turkey. 6 . Reasons for long inappropriate stay indicated that admission on a weekend and/or surgeon's operative schedule. for the post-operative period. which are expected not to stay more than a day.for complete recovery. which may be effective in improving the quality and efficiency of provided care. weekend inclusion. concerns for returning the healed patient to his unit may influence the physician to retain him for few days –rather than hours.(20). there is a need for regular reviews as a part of internal audit of in-service hospital to conserve scarce health care resources of university hospitals. On the other hand. the most frequent causes for inappropriate hospitalization were premature admissions. Recommendations: Several admissions to Urology Surgery Department can be managed as one-day surgeries. 5 87.67 91.17 87.83 100 7 .67 95.urethral resection of bladder neck Trans. replacement Prostate biopsy Testicular biopsy Trans.83 100 100 95.83 100 100 91.83 95. Epididymectomy Hydrocelectomy Meatotomy Nephrostomy tube insertion Orchidectomy Orchiopexy Penile prosthesis insertion.83 83.urethral resection of prostate(TURP) Ureteroscopy/ stone removal Urethral dilatation Varicocelectomy Response Frequency (n=24) 19 21 23 23 20 21 21 24 22 23 23 24 24 23 23 24 24 22 22 22 23 23 24 % 79. Urology surgical procedures Bladder biopsy Bladder instillation chemotherapeutics Circumcision Cystoscopy Cystolithotripsy Dilatation of the bladder neck.33 87.Further Studies: Further studies are required in different specialties and general medical and surgical wards to assess the rate of appropriateness/inappropriateness of hospital admissions and days. revision.83 95.5 100 91.urethral resection of bladder tumor (TURBT) Trans.83 95.83 95.5 95.67 91. as well as the reasons and delay factors for each inappropriate admission and/or hospitalization day. Table (1): One-day Urology surgical procedures recommended by surgeons. urethral meatus Dorsal slit in phymosis Extracorporeal Stock Waves Lithotripsy (ESWL).67 95. Table (2): Characteristics of the patients admitted to urology surgery department in year 2004: Characteristics Age in years: < 10 10 < 20 < 30 < 40 < 50 < 60 Gender: Male Female Type of admission: Out patient clinic.2 800 435 49.4 X2=16.1 Table (3) distribution of subjects according to their age.66 412 25.5 18.3 1195 74.35 18. Frequency (n = 1607) Percent (%) 207 116 220 185 292 282 305 12.02 F = 25.3 269 72.2 17. Gender: .Male: 629 78.7 38.8 7.6 1492 115 92. gender and intervention "Retrospective audit".6 38. Intervention: One-day surgery Multi-days surgery Non-operated cases.7 11.8922. Subjects Characteristics One-day n=800 % Intervention Multi days Miscellaneous Total n=435 % n=372 % n=1607 % Significance 1.4 25. Mean Age & SD: 171 21.6 297 68.77 103 27.0 1195 412 74.2 13.7 32.12 20.9 7.76 138 31.4 42. Emergency dept.001 8 .1 372 23.Female: 2.8 27.898* .9621.5 19.512* * P < 0. 5730) 6.79* 8156 44.83 4.61 ---- 6226 34. for the year 2004.564 (0. Duration of Hospital Stay (days) One day (n=800) %# Intervention Multi days Others (n=435) %# (n=372) %# Total (n=1607) %# Significance 1.001 Table (5): Distribution of subjects' inappropriate hospitalization days according to their age group and gender "Prospective audit 2005". Age: . Postoperative days: Number 2762 % 15.25 ---- 8210 44.21 2.19* 3. X SD Total LOS X SD 3. Inappropriate Hospitalization Days Characteristics of subjects 1.878 (0.92 7. (n= 5) Mann Whitney Z (P)* Preop.38 3464 18.00 2.08 7.90 2. (n=95) .3801) 2.05 Length Of Stay.96 6. Includes the operative days when applicable.87 4257 23.16 2. Total LOS: Number % X SD 7515 41.08 1.< 60 (n=76) 60 + (n=24) Mann Whitney Z (P)* 2.70 t-test = 12.67 6.0535) 2.11 1.00 1.75 10.52 0.6157) 6.39 7.54 # Percent is out of the grand total (18305) Length of Stay.84* 2.931 (0.09 X SD 3.56 2634 14.04 5.05 8.Female.62 9.45 4.49 0.58 17.92 0. Preoperative days: Number 3953 % 21.16 1. * P ≤ 0.Table (4): Distribution of subjects' hospital days according to the intervention. Gender: .07 2.18 4.60 1.0 10.26 9.00 2.Male.39 18305 100.55 1. 9 .05 1.18 t-test = 10.5770) 4.77 0.1045) * P < 0.01 5.558 (0.623 (0.72 0.65 7.502 (0.40 0.85 6.60 X SD 4.29 2. X SD Postop.79 8.94 5.95 7.65 F = 207.28 2. McDonagh MS.48 14 33 208 6. Bonnema J. 1998 April 25. McAleese P.84 597 100 References: 1. Ann Surg. BMJ. Postoperative: 1. 10 . 4. 6.57 4 1. Sub-Total Total Frequency Percent 34 2 277 8. Health Policy. Smith DH. A weekend. 2005. Odling-Smee W. 4. 5.51 71. Medical and Psychosocial Effects of Early Discharge after Surgery for Breast Cancer: Randomized Trial. Sub-Total II.74 0. Paul MA. Measuring Appropriate Use of Acute Beds. Premature admission. Br J Surg. Goddard M.03 389 65. 2. Geel AN.31 10 2. A weekend. Wiggers T. Preoperative: 1. 316:1267-71. 4.53 (3):157-84. 83:145-6.1994. Lack of family for home care. Schmitz PI. Wersch AM. 220: 740-4. Reasons of Inappropriate long stay I. 2.Outpatient Surgery. The Effect of Complications on Length of Stay. 3.com. 7. Pruyn JF.63 44 11. Doing follow-up procedures and/or treatment that can be done on an outpatient basis. 5.87 34.Table (6): Frequency Distribution of reasons of inappropriate longer hospital stay among patients scheduled for one-day surgeries "Prospective audit 2005".73 15. Discharge planned. Available at: http://www. Patient dropped from the schedule for any reason. Accessed Jul. A Systematic Review of Methods and Results.com/outpatient_surgery/article_em. 2000 Oct.16 4 1.21 18 4. The Changing Pattern of Surgery. E-medicine Health . Emedicinehealth.92 157 75.1996. Problem in scheduling surgery. Problem in scheduling diagnostic procedure. 3. 2.htm. Madern GJ.emedicinehealth. 3. but no orders written. Doing follow-up procedures and/or treatment that can be done on an outpatient basis. Results of diagnostic tests/procedures or consultation not yet received. 1994. Pedersen SH. 8. 14.1993. Nassali G. 62 :123-7.. Lillian R. 2003. 96:788-90. Available at: http://www. Eur J Surg Onco. Pediatrics.G. Eberlein TJ. and Kituuka O. and Economic Advantages of Accelerated Discharge after Surgical Treatment for Breast Cancer .BMJ. Holcombe C. Saunders Company. 2006. 15. 25-32. Douville LM. Kakande I. Hospital Stay for Healthy Term Newborns. The Shortened Hospital Stay. Aranaz JM.ncbi. Manitoba Center for Health Policy and Evaluation. The Satisfaction and Savings of Early Discharge with Drain in Situ Following Axillary Lymphadenectomy in the Treatment of Breast Cancer. Leutscher E.com/gm/Atoz/dc/caz/card/hatt/60short. 18. pp. University of Manitoba.br/request?js05020. Raffoul J. Bjorvell H. Boman L. Philadelphia: W.org. Anton P.).fcgi. Medical Short –Stay Unit in a Teaching Hospital. Accelerated Surgical Stay Programs: a Mechanism to Reduce Health Costs. Physical. Am. 2005 Sep. Kambouris A. Abenhaim HA. 2003. Clark JA.htm.Am Surg. Surg. 21: 604-6.gov/entrez/query. Am. Kahn SR. Barry V. 9.nih. Russell R. 219: 374-81. (23rd ed. Zolese G. Inappropriate Hospitalization Use in General Surgery Wards. Cir Esp. 163(11):1-10. Day Care Surgery: The Norm for Elective Surgery. Surg. 7. 11 . Discharge Outcomes for Long-Stay Patients in Winnipeg Acute Care Hospitals. Johnstone P. One – Day Hospitalization Following Modified Radical Mastectomy. Compan A. 2005. Kent RB. 17. Available at: http://www. 2000 November 28. Cedermark B.6. Bailey & Love's Short Practice of Surgery. Theve NO.lifesteps. East and Central African Journal of Surgery 2005 December 10. 10. Avroy A. In Burden N.ca/centres/mchp/reports.bioline. Accessed Jul. West N.B. Marilyn E. Systematic Review of the Effectiveness of Planned Short Hospital Stays for Mental Health Care.. Magnitude Associated Factors and Causes.nlm. Medical Network Inc. 318:138790.1999 May 22. 58: 239-42. et al. Available at: http://www. Peiro S. Psychological. Goethe JW. Calpena R. Accessed Jan. Eur J Surg. William OH. 2: 1-4. pp. Stephen A. Horgan K.1996. Available at: http://www. 19. Effects of Early Discharge from Hospital After Surgery for Primary Breast Cancer. Mansel RE. Arnold publishers. Factors Influencing Patient Selection. Wilking N.) Ambulatory Surgical Nursing. London. 1284-95. 16.C. 78(3):183-91. 11. (ed. Accessed May 2005. 2000. Program Description: a Hospitalist – Run. 159 : 67 –73 . CMAJ. 12. 2005.1995 October 4.1995.umanitoba. 13. 1992.jsp Accessed Jan.Becker MR. Alonso J. 24. and Bhalwar C. 21.. Appropriateness of Admission and Length of Stay in a Turkish Military Hospital. To Stay or Not to Stay.. Verheggen F. 91: 70-74. 28(6): 653-63. Panis L.A. Restuccia J. and Blanc T. and Verheggen F. 37: 6-13. 22. 50: 196–201. 2006.. 2004 Dec.. a Dutch Report. Using Length of Stay and Inactive Days in the Hospital to Assess Appropriateness of Utilization in Barcelona. 7: 227-232. Pop P. Munoz A. Inappropriate Use of Hospital Beds in a Tertiary Care Service Hospital. 28. Celik Y. 2000.C. Celik SS. 27. 25. Paccaud F... The assessment of Appropriate Hospital Stay.. Inappropriateness of Hospitalization in a Canadian Hospital. Santos-Eggimann B. Teke K. 61: 121124. Blanc T..nic. etal. Assessing the Necessity of Hospital Stay by Means of the Appropriateness Evaluation Protocol: How Strong is the Evidence to Proceed? International Society for Quality In Health Care. 25 (6): 373-83. Medical Appropriateness of Hospital Utilization: an Overview of the Swiss Experience. The Evolution of Hospital Utilization Review Methods in the United States. World Hospitals and Health Services 2002.in/maa/t05/i2/maat05i2p121... and Kisa A. 29. J. 9: 115-120. Panis L. 23.. Factors Affecting Appropriateness of Hospital Utilization in Two Hospitals in Turkey.. Med Syst. J Med Syst 2001 Dec. Gloor J. 2005. and Joubert GI. 7: 253-260. Int J Qual Health Care 1997. 14: 55-67. 30. Schopfer D. Available at http://medind. Int J Qual Health Care 1995.20. J Epidemiol Commun Health 1996.E. Kaya S. 12 . Int J Qual Health Care 2002. Comparing Results of Concurrent and Retrospective Designs in a Hospital Utilization Review. 12(6): 483-493. Spain. Inappropriate Use of Hospital Beds: A Case Study of University Hospitals in Turkey. MJAFI.. and Anto JM. and Capray J. Int J Qual Health Care 1995. Parmar B. Chakravarty L.pdf Accessed Jun. and Bulut HD. Sidler M.. Smeets P. Pediatrics 1993. Santos-Eggimann B. Pop P.. Kissoon N. 26.
Report "Appropriateness of Length of Hospital Stay for Patients Undergoing"