In this study, we evaluated the length of postoperative hospital stay in patients operated on for nonperforated acute appendicitis after a reorganisation oriented to same-day discharge. We showed that although the administratively enforced reorganisation was determined and executed in a short period of time, our immediate results were good. LOS was significantly shorter in patients treated at the ED than among those treated at the surgical ward postoperatively. The postoperative direction of the patient to the ED was successful in the majority of the cases after the reorganisation, despite the fact that the time to implement the new protocol for patient management was only a few weeks. This corresponds to a rather satisfactory initial compliance of the medical and nursery staff in the implementation of the new protocol. We also calculated a shorter operative time in patients who were observed in the ED compared to the patients who were directed to the surgical ward after the reorganisation. This finding implies that the operating surgeon’s clinical judgement remained the major determinant of maintaining safety concerning the postoperative triage.
Our findings concur with earlier studies, where early discharge of patients with non-perforated acute appendicitis was reported to be safe and effective (12, 13). A review of 13 studies with 1152 adult patients who underwent day-case appendicectomy reported that only 27% were discharged within 12 hours, 53% within 24 hours, and 21% within 72 hours (14). The cases of our study that were followed at the ED after the reorganisation (57.1%) approached a discharge within 13 hours from the operation. Thus, the majority of our Group 2 patients virtually reached the most favourable benchmark of the aforementioned review (14). Interestingly, there are further studies from the United States and Canada that have reported impressive results with a postoperative discharge within 3-4.7 hours in the majority of their series (45-86%) (12, 13). This was associated with a return-rate to the ED of 8 – 11.4% (the respective rate was 1.6% in our series) without any need for in-hospital readmission (12, 13). The Canadian study showed that the early-discharge policy resulted in a 45% reduction in the need for in-hospital beds (13). Same-day discharge is therefore feasible and effective. Possibly the variation in the length of postoperative stay between different centres can be attributed to modifiable local factors and results can be further improved with extensive training (15). In addition, early discharge is feasible and reliable also in paediatric patients (16).
An important aspect of the herein research is that it provides real-life results concerning early discharge after surgery for nonperforated acute appendicitis. To the best of our knowledge there is scarce evidence concerning early or same-day discharge from the Nordic Countries and particularly from Finland. It is interesting to note that the main proponent of non-operative management for nonperforated acute appendicitis, which is the APPAC multi-centre randomised trial from Finland between 2009 and 2012, did not take into account the potential benefits of early discharge to the comprehensive outcome. According to the APPAC conservative therapy with antibiotics was non-inferior to surgery (17). At 5 years, the majority (61%) of antibiotic group patients did not undergo appendicectomy and the overall costs of the surgical arm were 1.4 times higher (18, 19). No information was provided concerning the time from surgery to discharge (17). Moreover, in the surgery group, only standard open appendicectomy was performed (17) and possibly this may have contributed to a delayed discharge in the APPAC population compared to modern laparoscopic appendicectomy. On the contrary, it has been shown that early discharge after appendicectomy confers a significant reduction in the costs (20). We believe that the results of our study should be taken into account in this context, as the overall benefit of non-operative treatment for nonperforated acute appendicitis could be challenged from an aggressive early discharge policy after laparoscopic appendicectomy.
The potential weaknesses of a study with a retrospective design are contained in this series as the major end-points are electronically recorded during the routine clinical practice at our institution. The time of surgery and the time of discharge are always digitally documented on the spot. In addition, there is a valid electronic documentation of the 30-day complications due to a strict post-discharge policy that comprises direct telephone consultation from the patient’s family doctor and referral for complication management requisitely to our institution. On the other hand, there is a possibility of a selection bias given the fact that there was not a robust compliance to the reorganisation’s policy, at least during the initial 3-month period. Indeed, 15 out of the 35 patients were directed to the surgical ward instead of the ED, which could be explained in a lesser extent by the surgeon’s preference not to deviate from the previous routine (15). However, the finding that the former patients had a longer duration of the operation possibly reflects a relatively increased operative difficulty as the reason of the surgeon’s decision for an expert supervision at the surgical ward and with the intent not to compromise safety.
Although this study is based on a relatively small series, it shows that a major change in routine practice is feasible even at a short time and at a satisfactory compliance rate, and with immediate positive outcome in respect of the initial objective, which was the safe reduction of the postoperative LOS. Another interesting feature of the herein investigation is that the responsibility of the postoperative course of patients operated readily for nonperforated acute appendicitis can be safely assigned to a non-surgical specialty such as emergency medicine, and even at the level of doctors in training, with the provision of precise postoperative instructions by the surgeon and the readiness for a surgical consultation. In addition, the reorganisation exploited the inherent feature of the ED to discharge a patient over a wider time frame in order to reduce decisively the postoperative LOS. It is also possible that further reorganisation of the whole in-hospital management, and particularly a more active role of the recovery room to the early discharge, could result in an even shorter LOS than the one documented in this study (20, 21). Last, this study confirmed that surgery for nonperforated appendicitis bears minimal postoperative morbidity as there was not any significant complication in all the series. Therefore, despite its moderate sample-size, our study is in favour, that early discharge does not affect postoperative complication and readmission rate.