Reducing length of hospital stay following elective PLDD surgery has the potential to increase patient throughput, minimise risks of nosocomial infection and other adverse outcomes associated with prolonged hospital stay and promote early mobilisation.[6, 7] However, moving to a same-day discharge model of care, even for patients deemed low risk of adverse outcomes, is far from straightforward. Across all surgical specialties barriers to increasing same-day discharge rates identified in the GIRFT anaesthesia and perioperative medicine national report included a cultural reluctance to change current practice, a lack of same-day discharge infrastructure, a concern that outcomes would be compromised and a sense that same-day discharge rates were already 'optimal' for their patient population. Given these concerns same-day discharge must be shown to be safe. Although same-day discharge is generally viewed favourably by patients, gains in throughput cannot be at the expense of patient safety.[9, 10]
Our study is the largest study of its kind to look at the safety of same-day discharge PLDD. It builds on the limited previous work on day-case/same-day discharge for PLDD[2, 3] and other spinal procedures. We found substantial variation in rates of same-day discharge PLDD surgery across England, with a number of trusts performing more than half of PLDD for low risk patients with same-day discharge. We found no strong or consistent evidence that same-day discharge was unsafe in the cohort of patients studied. Although a higher emergency readmission rate for patients discharged earlier may have been expected, this does not appear to be the case, either in general or for specific complications. It is not clear why same-day discharge patients had a higher odds of repeat surgery within one year. However, it may be related to some aspect of presentation not accounted for by the covariates studied.
Outcomes for patients seen in trusts with high and low rates of same-day discharge were very similar. Same-day discharge will not be suitable for all patients. In rural areas, or where the surgery is conducted in a specialist centre, travel distances will preclude early discharge for some patients. Nevertheless, there appears to be potential for trusts with low rates of same-day discharge in low risk patients to substantially increase the number of patients discharge on the day of surgery. Increasing awareness of current same-day discharge practice and mechanisms and pathways used to achieve higher rates of early discharge may help more trusts meet these targets. Greater inter-trust collaboration and peer support via existing national clinical improvement initiates (such as the GIRFT programme and Model Hospital) may be one way of achieving this.[12, 13] More broadly, improvement in same-day discharge surgery delivery will be dependent on further development of preoperative risk stratification and assessment frameworks, promoting an expectation of same-day-discharge where appropriate and creating the cultural ability and infrastructure to allow same-day discharge as default.
Our study has a number of strengths. By using a national database, we were able to link readmissions to different hospital trusts than the one that performed the index procedure. This is particularly important for specialist procedures such as PLDD which are often performed at some distance from the patient's local emergency care hospital. The HES database is also relatively complete, with very few missing data, reflecting the link between data entry and provider payment.
The main limitation of our study is that we were unable to comment on clinical presentation directly. Same-day discharge patients could vary systematically from those staying overnight according to disease severity, time from symptom onset to intervention, degree and nature of functional impairment, imaging appearance or underlying health status. Our analysis of data for trusts with high and low rates of same-day discharge surgery will help to minimise such biases since it is unlikely factors related to clinical presentation will have varied systematically across regions of the country represented by these two groups of trusts.
Although the HES database includes data for all patient episodes, some data entry inconsistencies have been noted, mostly with regard to differences in coding practice for procedures across trusts. HES is limited in terms of the types of patient outcomes which can be studied. Data on patient quality of life and other patient reported outcomes would be valuable, allowing a deeper understanding of how procedure choice impacts on patient outcomes and experience. Although we report data on early return to hospital with pain, these are likely to be an under-report. We will only have captured the most severe cases of post-procedural pain; those requiring an emergency hospital admission. Finally, our study is observational and, for the reasons outlined above, is not definitive. A randomised controlled trial should be considered.