Impact of a 24-hour discharge pathway

on outcomes of pediatric
appendectomy
Luke R. Putnam, MD,a,b,d Shauna M. Levy, MD, MS,a,b,d Elizabeth Johnson, RN-BC, MA, MS, FAACM,d
Karen Williams, PharmD,d Kimberlee Taylor, MHA,d Lillian S. Kao, MD, MS,a,c,d
Kevin P. Lally, MD, MS,a,b,d and KuoJen Tsao, MD,a,b,d Houston, TX

Background. Clinical pathways for simple (nonperforated, nongangrenous) appendicitis potentially

could decrease hospital length of stay (LOS) through standardization of patient care. Our institution
initiated a simple appendicitis pathway for children with the goal of less than 24-hour discharge (same-
day discharge, SDD) and evaluated its effectiveness.
Methods. A prospective cohort of pediatric patients (<18 years of age) who underwent appendectomy for
simple appendicitis after implementation of a SDD pathway were compared with a historic cohort of similar
patients in this same large children’s hospital. Primary outcomes included LOS, surgical-site infections,
and readmissions. Mann Whitney U test, Fischer exact test, v2 test, and logistic regression were used.
Results. Between June 2009 and May 2013, 1,382 appendectomies were performed; 794 (57%) were for
simple appendicitis (316 prepathway and 478 pathway). Hospital LOS decreased 37% after pathway
implementation from a median (interquartile range) of 35 (20–50) hours to 22 (9–55) hours
(P < .001). SDD increased from 13% to 58% (P < .001). Infectious complications were unchanged
(1.6% vs 1.8%, P = .82), but readmissions increased (1.2% vs 4.2%, P = .02).
Conclusion. A standardized pathway for simple appendicitis that targets SDD can be achieved in
children; however, a slight increase in readmissions was noted. High risk for readmission, cost
effectiveness, and generalizability need to be further determined. (Surgery 2014;156:455-61.)

From the Center for Surgical Trials and Evidence-based Practice,a Departments of Pediatric Surgeryb and
Surgery,c University of Texas Medical School at Houston; and the Children’s Memorial Hermann Hospital,d
Houston, TX

INTEGRATED CARE PATHWAYS are becoming more com- 24-hour discharge (same-day discharge, SDD)
mon as a strategy for addressing the increasing pathways for laparoscopic surgery procedures,2-4
costs of health care and need for efficient use of re- and enhanced recovery after surgery pathways for
sources. These structured, multidisciplinary path- colorectal surgery.5
ways serve multiple purposes, including Appendicitis is the most common acute pediat-
introduction of evidence into practice, decrease ric condition requiring operative care,6 with
in physician variation in practice, and standardiza- demonstrated marked variations in care and use
tion of data for audit and continuous process of resources.7-10 Although standardized clinical
improvement.1 In addition, many such pathways pathways have been applied to appendicitis, few
have demonstrated decreased hospital length of studies have demonstrated the feasibility and
stay (LOS) without jeopardizing clinical outcomes. effectiveness of pathways dedicated to simple
Examples include same-calendar day or less than appendicitis patients while targeting SDD or
same-calendar day discharge as their primary direc-
tive, especially in children.11-13 Recognizing the
Presented at the 9th Annual Academic Surgical Congress in San
Diego, CA, February 4 6, 2014. variability, resource use, and clinical challenges in
Accepted for publication March 19, 2014.
postoperative care for these children, we set out
Reprint requests: KuoJen Tsao, MD, Associate Professor, Depart-
to evaluate outcomes after implementation of a
ment of Pediatric Surgery, The University of Texas School of standardized SDD pathway for pediatric simple
Medicine at Houston, 6431 Fannin St, Suite 5.254, Houston, appendicitis.
TX 77030. E-mail: [email protected].
0039-6060/$ - see front matter METHODS
Ó 2014 Mosby, Inc. All rights reserved. Setting. Children’s Memorial Hermann Hospi-
http://dx.doi.org/10.1016/j.surg.2014.03.030 tal (CMHH) is a 240-bed children’s hospital that is

SURGERY 455
456 Putnam et al Surgery
August 2014

integrated with its adult counterpart, Memorial Table I. Discharge criteria

Hermann Hospital Texas Medical Center. Nine
1. Temp <101.48F (oral) since admission or greater
board-certified or board-eligible pediatric sur-
than 24 h
geons performed all operations during the study
2. Tolerating regular diet
period.
3. Pain relief with oral analgesics
Patients. All patients younger than 18 years of
4. Ambulating with minimal assistance, as age
age admitted to CMHH and diagnosed intraoper-
appropriate
atively with simple appendicitis between June 2009
and May 2013 were included. A prospective cohort
of patients treated per the SDD pathway between
January 2011 and May 2013 was compared with a surgical-site infections (SSIs), unplanned emer-
historic cohort of prepathway patients between gency room (ER) or primary-care visits, and
June 2009 and December 2010. We excluded readmissions. An integrated postappendectomy
patients presenting for interval appendectomies SSI surveillance program between pediatric sur-
or who were diagnosed with gangrenous or perfo- gery and infection control monitored all inpatient
rated appendicitis at the time of operation. and outpatient SSIs for 30 days after discharge.
Protocol. Before the SDD pathway was imple- Patients who failed to be followed up in clinic were
mented, there was no standardized protocol for contacted by telephone. Incoming telephone
the treatment of acute appendicitis. The attending triage from patient and families were not consis-
surgeon of the day was responsible for patient tently recorded, however, which could further help
discharges. The SDD pathway was launched in to gauge the pathway’s resource use.
January 2011 and used a standardized, postopera- Clinical outcomes. The pathway was audited in
tive order set developed by a multidisciplinary August 2011 and May 2013, 8 and 29 months after
team of pediatric surgeons, operating room (OR) pathway implementation, respectively. Postopera-
and ward nurses, social workers, and case- tive superficial, deep, and organ/space SSIs, and
management personnel. The pathway consisted the number of and reasons for ER visits and
of: (1) initiation of a clear liquid diet immediately readmissions within 30 days were recorded based
postoperatively, (2) ambulation within 2 hours on chart review (prepathway) and prospective
after operation, (3) specific discharge criteria surveillance (pathway). All SSIs were confirmed
(Table I), and (4) daily ‘‘appendicitis rounds.’’ accordingly by physical examination and imaging.
Every afternoon, a fellow or attending surgeon as- In coordination with the infectious disease depart-
sessed postappendectomy patients for discharge. ment, the surgeons performed surveillance of
Patients and relevant family members were given appendicitis patients through clinic follow-up en-
written and oral discharge instructions before the counters, review of all ER visits at Memorial
patient was discharged. Standardized discharge Hermann Hospitals, and phone calls to patients.
pain medication included acetaminophen/hydro- Patient LOS was comprised of three components:
codone elixir. ER to incision (ER to OR), incision to closure
The majority of patients were referred from (Case Length), and closure to discharge (OR to
outside facilities and arrived with an inconsistent Discharge). Same-day discharge was defined as
battery of labs and imaging. Given these variations LOS less than 24 hours.
in initial workups, the pathway focused exclusively Cost analyses. Cost data were obtained through
on their postoperative care. Patients may or may the hospital cost accounting system. Direct costs
not have received broad spectrum antibiotics were used as the pathway only affected this
before their transfer to CMHH; once in our portion of the total hospital costs. The direct
institution, only preoperative antibiotics were cost of the operating room was excluded because
administered per clinical guidelines. Techniques the pathway did not change intraoperative prac-
for appendectomies were determined by surgeon tices. The remaining direct costs were averaged
preference and included 3-port and single-port for the pre-pathway and pathway cohorts to
laparoscopy and open approaches. determine the cost per encounter. Importantly,
Follow-up. During the prepathway period, pa- the costs of readmissions and post-discharge
tients were only given a follow-up appointment adverse events such as SSIs were not obtainable
within 2 weeks of discharge. In addition to the for this study and may limit the applicability of the
appointment, during the pathway period, physi- results.
cians documented on a postappendectomy form Differences between groups were assessed by
postoperative complications or events such as the use of Mann Whitney U tests for continuous
Surgery Putnam et al 457
Volume 156, Number 2

Table II. Characteristics of prepathway and pathway groups

Pathway
Prepathway Audit #1 P value Audit #2 P value
Operations, n 316 146 332
Laparoscopic, n (%) 284 (90%) 137 (94%) .10 321 (97%) <.001
Single-port, n (%) 0 (0%) 15 (10%) <.001 30 (9.0%) <.001
Male:female 1.70 1.52 .58 1.74 .88
Age, y 10 (5 15) 9 (5 14) .78 10 (6 14) .93
Body mass index, kg/m2 19 (13 25) 20 (14 26) .98 19 (13 25) .50
Duration of stay, h 35 (20 50) 24 (12 36) <.001 22 (9 55) <.001
ER to OR, h 10 (2 18) 9 (1 17) .02 7 (1 13) <.001
Case length, min 33 (14 52) 37 (20 54) .63 36 (20 52) .28
OR to discharge, h 24 (17 31) 18 (5 31) <.001 15 (1 29) <.001
Same-day discharge, n (%) 42 (13%) 75 (51%) <.001 195 (58%) <.001
Surgical-site infection, n (%) 5 (1.6%) 7 (4.8%) .04 6 (1.8%) .82
ER visits, n (%) 6 (1.9%) 7 (4.8%) .08 17 (2.1%) .03
Readmissions, n (%) 4 (1.2%) 3 (2.1%) .52 14 (4.2%) .02
Values noted are median (interquartile range) unless otherwise specified.
ER, Emergency room; OR, operating room.

variables and v2 or Fisher exact tests for categorical

variables; logistic regression was performed to eval-
uate risk factors for readmission using Stata 13.1
(College Station, TX). Variables with P < .2 on uni-
variate analyses were entered into the initial regres-
sion model in a backward step-wise fashion.

RESULTS
Demographics. A total of 1,382 appendectomies
were performed between June 2009 and May 2013;
794 (57%) were for simple appendicitis (316
prepathway and 478 pathway). Patient demo-
Fig 1. Breakdown of time spent in hospital. The average
graphics, including sex, age, and body mass index patient’s total LOS (widely spaced, dashed line), time
were similar between the pre- and postpathway from operative closure to discharge from the hospital
cohorts; a greater proportion of laparoscopic (OR to discharge, solid line), and time from ER to the
appendectomies were performed in the pathway time of incision (ER to OR, narrowly spaced dashed
group (P = .001, Table II). No single-port laparo- line) were all decreased after implementation of the
scopic appendectomies were performed during SDD pathway (P < .001).
the prepathway period, whereas 9.4% of laparo-
scopic cases during the pathway period were time from ER to OR decreased from 10 to 7 hours
done with a single-port. Approximately 80% of all (P < .001). Duration of the operation was un-
patients were referred from more than 40 outside changed (33 vs 36 minutes, P = .28).
health care facilities; there was no difference in In addition, the clinical pathway increased
the percentage of referrals pre- and postpathway same-calendar day discharges from 8% to 32%
(83% vs 82%, P = .77). during the study period (P < .001, Fig 2). The
Clinical outcomes. Hospital LOS decreased by pathway’s impact was even more pronounced for
37% after pathway implementation from a median patients who underwent appendectomies before
(interquartile range) of 35 (20 50) hours to 22 noon. Although patients may be admitted during
(9 55) hours (P < .001). The time from OR to evening hours or overnight, our clinical practice
discharge decreased from 24 (17 31) hours to is to perform nonemergent appendectomies the
15 (1 29) hours (P < .001, Fig 1). As a result, following morning. As a result, 179 (69%) of
SDD increased from 13% to 58% (P < .001). pathway patients met discharge criteria and were
Although not targeted by the pathway, the median able to be discharged later that same day,
458 Putnam et al Surgery
August 2014

Table III. Reasons for ER visits

Pathway
Prepathway Audit #1 Audit #2
Abdominal pain, n (%) 1 1 6
GI-related, n (%) 2 1 4
SSI, n (%) 2 2 3
Wound check, n (%) 0 3 1
Other, n (%) 1 0 3
Total ER visits, n (%) 6 (1.9%) 7 (4.8%) 17 (5.1%)
ER, Emergency room; GI, gastrointestinal; SSI, surgical-site infection.
Fig 2. Average percentage of same-calendar day
discharge per fiscal year quarter (FYQ). The average per-
centage of same-calendar day discharges for simple
appendicitis patients per fiscal year quarter (gray boxes) Table IV. Reasons for readmissions
increased during the study period with an R2 of 0.72. Pathway
Prepathway same-calendar day discharge was achieved
for an average of 7.6% of patients, which increased to Prepathway Audit #1 Audit #2
32% of patients in the pathway period (P < .001). SSI, n (%) 3 (0.9%) 3 (2.1%) 3 (0.9%)
Abdominal pain, n (%) 1 (0.3%) 0 5 (1.5%)
Nausea/vomiting, n (%) 0 0 3 (0.9%)
compared to 39 (23%) of the prepathway patients Colitis, n (%) 0 0 2 (0.6%)
(P < .001). Other, n (%) 0 0 1 (0.3%)
An increased rate of SSIs was noted at the time Total readmissions 4 (1.2%) 3 (2.1%) 14 (4.2%)
of the first audit (1.6% vs 4.8%, P = .04), but SSIs n, (%)
returned to the prepathway range at the time of SSI, Surgical-site infection.
the second audit (2.1%, P = .62). Increased ER
visits (1.9% vs 4.8%, P = .08) and readmissions
(1.2% vs 2.1%, P = .52) were noted during the first the multidisciplinary surveillance efforts after im-
audit which became statistically significant at the plementation of the pathway (P = .12).
second audit (2.1%, P = .03 and 4.2%, P = .02, Economic outcomes. In a similar fashion to
respectively). Reasons for ER visits and readmis- LOS data, the average cost per encounter during
sions are listed in Tables III and IV, and additional the prepathway period was $3,090 ± $996, which
details of the pathway readmissions are included in decreased to $2,719 ± $926 at the time of audit #1
Table V. With 4.2% readmissions during the but subsequently increased to $2,988 ± $1,024 at
pathway period (vs 1.2% in the prepathway the time of the second audit. Yearly cost savings
period), we would expect to readmit six additional during the pathway period was $49,053.
patients per year.
Although all patients were classified as having DISCUSSION
simple appendicitis based on intraoperative assess- Our SDD pathway increased the percentage of
ment, 12.8% (102/794) patients had gangrenous pediatric patients with simple appendicitis being
or perforated appendicitis on final pathology discharged home within 24 hours of admission.
suggesting misclassification (Table VI). Patients The SDD pathway, however, also was associated
with gangrenous or perforated appendicitis had with increased readmissions for nausea and pain;
more than three times higher odds of readmission these problems require further modifications to
when adjusted for age (odds ratio 3.48, 95% confi- the pathway and ongoing monitoring of outcomes.
dence interval; 1.42–8.54, P = .006, Table VII). Multiple studies have demonstrated that care
The vast majority of appendectomies were pathways for appendicitis decrease postoperative
performed between 7 a.m. and 6 p.m. for both LOS and sustain or improve outcomes,11-20 yet
cohorts (99% vs 97%, P = .84). A greater propor- most of these studies are either performed in
tion of post-pathway patients were discharged after adults or do not focus on SDD as a primary direc-
6 p.m. (19% vs 34%, P = .06), which was associated tive. Alkhoury et al11 carried out an observational
with a non-statistically significant increase in read- study of a same-calendar day discharge pathway
missions (0% vs 4%, P = .14). Fifty-eight percent for simple appendicitis in children using the
follow-up was documented during the prepathway ambulatory surgery suite for patients diagnosed
period, and 70% follow-up was achieved through during working hours. By doing so, the team was
Surgery Putnam et al 459
Volume 156, Number 2

Table V. Characteristics of pathway readmissions

Reason for readmission n (%) Median post-DC day (IQR) Median LOS (IQR) Analgesia, IV, n (%) Antibiotics, IV/PO, n (%)
Supportive care 9 (53) 3 (1.7–3.5) 2 (1.5–2.5) 6 (67) 2 (22)
SSI 6 (35) 6 (3.5–9.1) 1 (1–3.25) 6 (100) 6 (100)
Superficial 4 (67) 9 (6.9–10.1) 1 (0.75–1) 4 (100) 4 (100)
Deep 2 (33) 3 (2.4–3.1) 7 (5.3–7.8) 2 (100) 2 (100)
Other* 4 (12) 3 (2.4–10.0) 1 (1 1) 2 (100) 0 (0)
*Other: aseptic meningitis, duodenal ulcers.
DC, Discharge; IQR, interquartile range; IV, intravenous; LOS, length of stay; PO, oral; SSI, surgical-site infection.

Table VI. Breakdown of final pathology appendicitis, who are high risk for readmission,
Prepathway Pathway P value were seen in the postpathway group (11.7% vs
13.5%, P = .40). This slight increase may have
Simple, n (%) 267 (85%) 379 (79%) contributed in part to the increased readmission
Gangrenous, n (%) 32 (10%) 60 (13%)
rate, suggesting that some patients may be under-
Normal, n (%) 10 (3.2%) 25 (5.2%)
treated with the simple appendicitis pathway. Sec-
Perforated, n (%) 5 (1.6%) 5 (1.0%)
Other, n (%) 2 (0.6%) 9 (1.9%) ond, some patients may have been discharged
Total, n 316 478 .20 too soon after general anesthesia. Despite all pa-
tients meeting discharge criteria, postoperative
pain, and nausea were the most common reasons
for readmissions. Although not statistically impor-
Table VII. Univariate analysis of risk factors for tant, more pathway patients were discharged after
readmission 6 p.m., and readmissions were more frequent for
these patients. In the prepathway era, patients
Odds 95% confidence P
Risk factor ratio interval value
who met discharge criteria often stayed overnight
based on family and/or clinical convenience.
Younger age 0.90 0.80–1.02 .085 Operative technique was surgeon-dependent
Male sex 1.04 0.43–2.51 .928 during the study period, and a greater number of
Greater body mass index 0.98 0.91–1.06 .592 3-port and single-port laparoscopic cases were
Open appendectomy 1.48 0.34–6.50 .607
performed during the pathway period (Table II).
Longer case length 1.00 0.98–1.02 .905
Greater duration of stay 1.01 0.99–1.02 .403
These approaches were not associated with
Complicated pathology* 3.63 1.49–8.86 .005 decreased readmissions. Given that there were no
single-port cases performed in the pre-pathway
*Final pathology demonstrated gangrenous or perforated appendicitis.
period, the impact of this operative approach
could not be statistically examined. There is litera-
able to avoid admitting the majority of patients to ture to suggest that open or single-port appendec-
the hospital ward altogether. They demonstrated tomies may increase post-operative pain,22 but the
no change in SSIs or readmissions. Bensard limited number of these procedures performed for
et al12 implemented an early discharge pathway our cohorts make them less likely to be con-
for simple appendicitis at a large academic chil- founders of our results. In fact, our results may
dren’s hospital and increased their discharges be more generalizable and reflective of larger prac-
within 24 hours. Both of these studies, however, tices where significant variation in approaches is
contained small sample sizes and did not look at present.23
sustainability beyond 6 12 months. As part of the implementation of the pathway,
Despite an increase in readmissions of our surgical providers created clear expectations for
pathway patients, the readmission rate still is the patients and their families that if the operation
within national children’s hospitals standards for was performed in the morning, patients are able to
simple appendicitis.21 The reasons for increased return home the same afternoon or evening once
readmissions may be multifactorial. First, there is discharge criteria are met. For afternoon or
a potential for misclassification of disease at the evening operations, the expectations were for
time of operation. Although the pathologic diag- discharge the following morning. In conjunction
nosis does not determine the treatment pathway, with a more conscientious effort to meet SDD
more patients with gangrenous and perforated targets such as afternoon ‘‘appendicitis rounds,’’
460 Putnam et al Surgery
August 2014

all patients were discharged if they met criteria and hospital. Surg Laparosc Endosc Percutan Tech 2008;18:
if timing was reasonable. We did not document 267-71.
5. Walter CJ, Collin J, Dumville JC, Drew PJ, Monson JR.
whether or not patients were kept overnight due to Enhanced recovery in colorectal resections: a systematic re-
specific patient or family requests, but our team view and meta-analysis. Colorectal Dis 2009;11:344-53.
members readily offer this option if it necessary. 6. Alexander F, Magnuson D, DiFiore J, Jirousek K, Secic M.
One limitation of this study was incomplete Specialty versus generalist care of children with appendi-
follow-up which may have resulted in an underes- citis: an outcome comparison. J Pediatr Surg 2001;36:
1510-3.
timation of complications and readmissions during 7. Rice-Townsend S, Barnes JN, Hall M, Baxter JL, Rangel SJ.
the study period. Second, this single-center, Variation in practice and resource utilization associated
before-and-after study is subject to temporal con- with the diagnosis and management of appendicitis at free-
founders, regression to the mean, and other standing children’s hospitals: implications for value-based
methodologic flaws.24 False-positive and false- comparative analysis. Ann Surg 2014;259:1228-34.
8. Muehlstedt SG, Pham TQ, Schmeling DJ. The management
negative results may have resulted as the intervals of pediatric appendicitis: a survey of North American Pedi-
for assessment were not pre-planned. In review of atric Surgeons. J Pediatr Surg 2004;39:875-9.
Fig 1, it is possible that the results would have 9. Smink DS, Finkelstein JA, Kleinman K, Fishman SJ. The ef-
been different if the audit was performed at fect of hospital volume of pediatric appendectomies on the
different time intervals; however, the pathway misdiagnosis of appendicitis in children. Pediatrics 2004;
113:18-23.
period was 29 months after implementation 10. Newman K, Ponsky T, Kittle K, Dyk L, Throop C, Gieseker
without substantive changes in the clinical practice K, et al. Appendicitis 2000: variability in practice, outcomes,
or the pathway. In addition, despite the fluctuation and resource utilization at 30 pediatric hospitals. J Pediatr
in the results (Fig 1), the overall LOS and OR to Surg 2003;38:372-9.
discharge time decreased in the pathway period. 11. Alkhoury F, Burnweit C, Malvezzi L, Knight C, Diana J,
Pasaron R, et al. A prospective study of safety and satis-
Last, a cost analysis is an important component faction with same-day discharge after laparoscopic appen-
of quality improvement initiatives.25 Our cost anal- dectomy for acute appendicitis. J Pediatr Surg 2012;47:
ysis did not include readmissions or postdischarge 313-6.
SSIs, which may contribute to the total cost per 12. Bensard DD, Hendrickson RJ, Fyffe CJ, Careskey JM,
patient. Azizkhan RG. Early discharge following laparoscopic ap-
pendectomy in children utilizing an evidence-based clin-
In summary, a clinical pathway for pediatric ical pathway. J Laparoendosc Adv Surg Tech A 2009;19:
patients with simple appendicitis that aims to s81-6.
standardize care and targets SDD as its primary 13. Velhote CE, Velhote TF, Velhote MC, Moura DC. Early
function is feasible and successfully decreased LOS discharge after appendicectomy in children. Eur J Surg
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