By AMY KRAMBECK, MD
The
trend toward less invasive procedures, shifting from inpatient to outpatient, has
changed the face of surgery. Industry-changing leaps in technology and surgical
techniques have allowed us to achieve our treatment goals with smaller
incisions, laparoscopy and other “closed” procedures, less bleeding, less pain,
and lower complication rates. As a result, patients who used to require days of
recovery in the hospital for many common surgeries can now recuperate in their
own homes.
Outpatient
procedures grew from about 50% to 67% of hospitals’
total surgeries between 1994 and 2016,1,2 and outpatient
volume is expected to grow another 15% by 2028,3 with advantages for
patients, surgeons, insurers, and hospitals. In my hospital, where bed space is at a premium, my colleagues and
I were able to make a significant impact by switching minimally invasive
surgery for enlarged prostate, also called benign prostatic hyperplasia (BPH),
from inpatient to outpatient.
New
Opportunity with an Advanced Technology
BPH affects
about half of men in their 50s, with the prevalence increasing with age to include
about 90% of men 80 and older.4 As a result, BPH surgery makes up a significant
portion of urological procedures in any hospital.
I
have been performing BPH surgery for 11 years. There are several options,
including transurethral resection of the prostate (TURP) and suprapubic
prostatectomy, both of which require hospital stays and bladder irrigation with
a catheter due to bleeding. Another less frequently utilized surgical option for BPH is holmium
laser enucleation of the prostate (HoLEP). HoLEP causes fewer complications and
requires shorter hospitalization.5 Specifically, its postoperative
morbidity is the lowest among BPH surgeries.5,6,7 HoLEP has the
least bleeding, shortest catheter time, and low rates of urinary tract
infection, plus patients are less likely to require additional treatment for
BPH as they age compared to other available therapies.5,6,7
Last
year, my colleagues and I began using a Lumenis 120-watt holmium
laser with MOSES Technology that modulates
the laser pulse, building
on HoLEP’s advantages in a procedure called MOSES laser enucleation
of the prostate (MoLEP). Simultaneously
cutting and cauterizing in a very controlled fashion, MoLEP improves hemostasis
and significantly reduces surgical time and anesthesia use. With these
advantages and very little bleeding after surgery, we found that patients did
not need prolonged irrigation in the hospital. We began to feel comfortable with
the idea of discharging patients after MoLEP surgery – a change we knew would
make a major impact at our hospital
because BPH surgery is so common.
Making the Outpatient Change
Historically,
my hospital had been through many surgical advances and transitions to the
outpatient model. The move must be made with caution each time. Although we
were highly confident in patients’ ability to safely leave the hospital after
MoLEP, we needed to track the success of this approach and identify any areas
for improvement. Thus, we spent several months collecting baseline data on MoLEP
patients who stayed at the hospital overnight.
Reviewing
everything that happened inside the hospital, we saw no reason to keep patients
after surgery unless they had acute comorbidities. Even patients with very
large prostates or those taking blood thinners could safely recuperate at home.
Eight
months ago, we began releasing patients the day of MoLEP surgery and tracking
the outcomes. To date, no MoLEP outpatients have come into the ER with
complications. We are beginning to see positive trends in the data, including
better bladder voiding the day after surgery, which we think may be traced to patients’
tendency to get up and move around at home and the absence of narcotics in
at-home recovery. We have
found that patients who discharge home are more likely to successfully urinate
on their own after the catheter is removed the next day than patients that stay
in the hospital overnight.
Since
we started performing MoLEP, I have discharged over 100 patients home the same day.
We are keeping some patients overnight – specifically those with significant
medical comorbidities, concurrent other procedures, or those who do not meet
discharge requirements.
The Effect on Our Hospital
The
hospital has responded favorably to the same-day discharge. Our level I trauma
center runs near capacity, so it helps that by discharging healthy MoLEP
patients home, we are freeing up hospital beds for more acute patients. The
change has led us to review our outcomes with other surgical procedures and
take steps to shorten hospital stays. My colleagues and I will continue to explore
less invasive surgical techniques that may allow more patients to recover at
home while we focus on more acute cases in the hospital.
Amy E. Krambeck, MD, is the Michael O. Koch Professor of Urology at Indiana University School of Medicine in Indianapolis.
The post Switching to Outpatient Surgery for Everyone’s Benefit appeared first on The Health Care Blog.
