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Appropriateness of Length of Hospital Stay for Patients Undergoing

One-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 patients
own environment results in better psychological adjustment as a result of enhanced patient
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comfort, control, independence, and better interaction with family members.(13) Also,
children benefit significantly from one day surgery as it decreases separation from their
family and home.(14) One day surgery reduces medications prescribed, uses the doctors
time more efficiently and does not increase the incidence of wound infection.(2) Moreover,
long hospital stay is detrimental for patients as hospitals are not safe and patients are at risk
for developing infections

(15)

, having bad reactions to medications,(6) or, having difficulty

in re-entering the real world, as well as exposure to have a higher rate of unemployment. (9)
On the other hand, long stay patients utilize a considerable proportion of inpatient hospital
resources. This may be an inappropriate over or under utilization of acute care resources
when patients could be discharged home. (16) The aim of the present study was to:
1. Identify acceptable one-day surgeries for patients admitted in urology surgery
department as recommended by surgeons.
2. Determine days of hospitalization among patients admitted for any of the
recommended one-day surgeries scheduled in 2004.
3. Identify reasons associated with current inappropriate hospital stay for patients
scheduled for any of recommended one-day surgeries.

Methodology:
Setting:
The study was conducted at the medical record department and the urology surgery
department. at Alexandria Main University Hospital.

Subjects:

Surgeons: Twenty four urology surgeons from urology department, faculty of


medicine including professors, assistant professors, lecturers, assistant lecturers
and residents conducting various types of urology surgeries participated in the
study;

Patients: One hundred patients admitted, and scheduled for recommended oneday surgeries, were involved in the study process,

Tools:
Three tools were used to collect data:
1. 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.
The list of surgeries was derived from the pertaining literature (17, 18).

2. Retrospective Surgery Review Sheet: was developed to gather the required


information through auditing medical records over one year, 2004. Data collected
included patient's age, gender, source of admission (OPC or RR), final diagnosis,
intervention, and dates of admission, operation and discharge.

3. Appropriateness of Hospital Stay Sheet: This tool was derived from Appropriateness
Evaluation Protocol (AEP)

(19)

. The AEP is an international protocol intended to

assess if the admission, and hospitalization days, are appropriate or not, and reasons
of appropriateness and inappropriateness for each. 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. Data included were
patient's age, gender, admission date and source, provisional and final diagnosis, date
of the operation, date of discharge, appropriateness of each hospitalization day, and
reason(s) for inappropriate preoperative and postoperative hospital stay.
Method of data collection:
After the official approvals were obtained, data were collected in two phases:
a. Retrospective Review Phase:

In order to examine the applicability of conducting the selected surgical


procedures, as reflected in literature, in one-day surgery system in the study
setting, the urology surgeons were asked to complete the "One-Day Surgery
Opinnionnaire". Twenty four faculty members responded. 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.

All medical records of the patients admitted to the urology surgery department
through out the year 2004 were obtained and reviewed, using the "Retrospective
Surgery Review Sheet". The total number of records was 1607. The surgical
procedures were categorized as either of one-day or multi-days types.

b. Prospective Phase:

Monitoring of 100 patients admitted to the department, and scheduled for any of
the recommended one-day surgeries, was done over a period of two months.
Their records were being reviewed daily from the day of admission till
discharge. Each day was assessed for its appropriateness/inappropriateness of
stay in urology department. Reasons for inappropriateness either preoperatively
or postoperatively were assessed for each inappropriate day.
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Statistical Analysis:
SPSS version 11.5 was used for data entry and analysis. The retrospective Analysis focused
on classifying patients according to intervention, either one-day surgery, multi-day surgery,
or cases with no surgical intervention but stayed for receiving treatment, diagnostic
procedures, or follow-up. In case of operative interventions, preoperative, postoperative,
and total Length of Stay (LOS) were calculated to determine inappropriate days. 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, adding days as
necessary when the patients stay extends over one or more month endings. Moreover,
preoperative stay was calculated by subtracting date of admission from the date of the
operation, whereas postoperative stay was calculated by subtracting preoperative stay from
the LOS and average LOS was computed as total LOS divided on total discharges.
Results:
a) Retrospective review:
Table 1 illustrates the Urology surgical procedures recommended by surgeons to be
regarded as one-day surgeries. It included those procedures reported by 70 % of the
involved surgeons or more. Nephrostomy tube insertion, Orchidectomy, Prostate biopsy,
Testicular biopsy, Extracorporeal Stock Waves Lithotripsy and Varicocelectomy were
recommended by all surgeons to be conducted as one-day procedure, while Bladder biopsy
was recommended by only 79.17% of the surgeons.

Table 2 illustrates Characteristics of the patients admitted to Urology Surgery


Department in year 2004. 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). Majority of patients were
males (74.45%) and were mainly admitted to the unit through the outpatient clinic (92.8%).
Twenty three percent of subjects discharged without undergoing a surgical procedure,
though they received medical treatment, investigations done and/or other diagnostic
procedures (23.1%). About half of the reviewed records were had belonged to patients
scheduled for one-day surgery (49.8%), and 27.1 % were admitted for multi-days surgeries.

Table 3 shows distribution of subjects according to their age, gender and type of
intervention. The table indicates that the difference among the three interventions were
statistically significant in both gender and age. For gender, 78.6% of the patients scheduled
for one-day surgeries were males (X2 = 16.898, P < 0.05), while in relation to age, patients
who were scheduled for one-day surgeries were significantly older than those scheduled for
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longer stays, (X = 42.1220.76 years, 38.3518.77 years, 32.8922.66 years) respectively.


(F = 25.512, P < 0.05).

Table 4 shows the distribution of subjects' hospital days according to the intervention. It
indicated that the total length of hospital stay for reviewed subjects (7515 days)
representing 41.05% of the total length of stay for all subjects (18305 days), and that only
10.65% of these days were appropriate. Moreover, for surgical procedures that should
consume not more than one day of hospital stay, the mean length of stay for one-day
surgery was 8.39 7.58 days, with a preoperative stay of 4.945.87 days, and postoperative
stay of (3.454.38 days).
b) Prospective review:
Table 5 reviews the inappropriate hospitalization days as distributed by the subjects' age
group and gender. It was indicated that both parameters (age and gender) had no statistical
significance in relation to the inappropriate stay. Patients aged more than 60 years old
stayed longer preoperatively (4.29 2.49). Moreover, males were found to stay longer pre
and postoperative days than females.

Table 6 illustrates reasons of inappropriate longer hospital stay among patients scheduled
for one-day surgeries. For long preoperative stay, it was found that in most cases,
premature admission (71.21%) was the most frequent reason. However, patient's stay to
carry out diagnostic procedures and/or treatment revealed the highest frequency of
inappropriateness reasons (75.48%), followed by lack of family for home care (15.87%).

Discussion:
The study was primarily conducted to assess the rate of inappropriate hospitalization days
among one-day urology surgery patients. 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, 30)

(20-29)

. Parallel with the results of the present study, Anton

found that surgical specialty units usually have higher numbers

of unnecessary hospital days. Inappropriate days of hospitalization, in a tertiary care


specialty unit, equipped with highly trained health care providers and administrators, 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. This
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justification was advanced by Chakravarty etal.(20), and Teke etal

(28)

. Moreover, the

hospital receives patients from peripheral hospitals and care settings, which may not have
adequate investigation facilities and thus, these patients need substantial workup before any
definitive management. In addition, concerns for returning the healed patient to his unit
may influence the physician to retain him for few days rather than hours- for complete
recovery. These justifications were highlighted in Celik etal (24) in a case study conducted in
a University Hospital in Turkey. It was advanced that inappropriate post-minor surgery stay
was due to surgeons fears from the home environment, particularly in rural areas where
necessary care during the period of recovery or timely medical aid in an emergency would
not be ensured. This factor might have influenced the urology surgery specialists to retain
the patients for evaluation and monitoring

(21)

, or conducting diagnostic procedures and/or

treatments that could have been carried out on an ambulatory basis

(27)

. Reasons for long

inappropriate stay indicated that admission on a weekend and/or surgeon's operative


schedule, as well as follow up procedures as causes for prolonged one-day surgery stay and
are indicative of lack of organizational resource misutilization (22).

Conclusion:
In conclusion, the study documented a substantial proportion of inappropriate hospital
use under the current system of hospital services. On the other hand, the most frequent
causes for inappropriate hospitalization were premature admissions, weekend inclusion,
and problems in scheduling surgery, for the preoperative period, and doing diagnostic
procedures and/or treatment that can be done on an outpatient basis, as well as lack of
family for home care, for the post-operative period.

Recommendations:
Several admissions to Urology Surgery Department can be managed as one-day
surgeries, which are expected not to stay more than a day. Moreover, applying such system
needs multidisciplinary collaboration to change in the physicians behavior for more
efficient utilization of hospital resources. Additionally, strategic changes are required in the
organization of unit routine activities and utilization management, which may be effective
in improving the quality and efficiency of provided care. Furthermore, 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.

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, 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.

Urology surgical procedures


Bladder biopsy
Bladder instillation chemotherapeutics
Circumcision
Cystoscopy
Cystolithotripsy
Dilatation of the bladder neck, urethral meatus
Dorsal slit in phymosis
Extracorporeal Stock Waves Lithotripsy (ESWL).
Epididymectomy
Hydrocelectomy
Meatotomy
Nephrostomy tube insertion
Orchidectomy
Orchiopexy
Penile prosthesis insertion, revision, replacement
Prostate biopsy
Testicular biopsy
Trans- urethral resection of bladder tumor (TURBT)
Trans- urethral resection of bladder neck
Trans- 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

%
79.17
87.5
95.83
95.83
83.33
87.5
87.5
100
91.67
95.83
95.83
100
100
95.83
95.83
100
100
91.67
91.67
91.67
95.83
95.83
100

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.
Emergency dept.
Intervention:
One-day surgery
Multi-days surgery

Non-operated cases.

Frequency
(n = 1607)

Percent (%)

207
116
220
185
292
282
305

12.9
7.2
13.7
11.5
18.2
17.5
19.0

1195
412

74.4
25.6

1492
115

92.8
7.2

800
435

49.8
27.1

372

23.1

Table (3) distribution of subjects according to their age, gender and intervention
"Retrospective audit".
Subjects
Characteristics

One-day
n=800 %

Intervention
Multi days
Miscellaneous
Total
n=435 %
n=372 %
n=1607 %

Significance

1. Gender:
- Male:

629

78.6

297

68.3

269

72.3

1195

74.4
X2=16.898*

- Female:
2. Mean Age &
SD:

171

21.4

42.12 20.76

138

31.7

38.35 18.77

103

27.7

32.8922.66

412

25.6

38.9621.02 F = 25.512*

* P < 0.001

Table (4): Distribution of subjects' hospital days according to the intervention, for the
year 2004.
Duration of
Hospital Stay
(days)

One day
(n=800) %#

Intervention
Multi days
Others
(n=435) %# (n=372) %#

Total
(n=1607) %#

Significance

1. Preoperative days:
Number
3953
%
21.60
X SD
4.94 5.87

4257
23.26
9.79 8.25

----

8210
44.85
6.65 7.18

t-test = 10.84*

2. Postoperative days:
Number
2762
%
15.09
X SD
3.45 4.38

3464
18.92
7.96 6.61

----

6226
34.01
5.04 5.70

t-test = 12.79*

8156
44.56

2634
14.39

18305
100.0
10.62 9.65

F = 207.19*

3. Total LOS:
Number
%
X SD

7515
41.05
8.39 7.58

17.75 10.95

7.08 7.54

Percent is out of the grand total (18305)


Length of Stay, Includes the operative days when applicable.
* P 0.001

Table (5): Distribution of subjects' inappropriate hospitalization days according


to their age group and gender "Prospective audit 2005".

Inappropriate Hospitalization Days


Characteristics of subjects

1. Age:
- < 60
(n=76)
60 + (n=24)
Mann Whitney Z
(P)*
2. Gender:
- Male. (n=95)
- Female. (n= 5)
Mann Whitney Z
(P)*

Preop.
X SD

Postop.
X SD

Total LOS
X SD

3.90 2.18
4.29 2.49
0.878
(0.3801)

2.11 1.16
1.92 0.72
0.564
(0.5730)

6.00 2.67
6.21 2.77
0.558
(0.5770)

4.07 2.28
2.40 0.55
1.931
(0.0535)

2.08 1.05
1.60 1.52
0.502
(0.6157)

6.16 2.83
4.00 2.00
1.623
(0.1045)

* P < 0.05

Length Of Stay.

Table (6): Frequency Distribution of reasons of inappropriate longer hospital


stay among patients scheduled for one-day surgeries "Prospective audit 2005".
Reasons of Inappropriate long stay
I. Preoperative:
1. Problem in scheduling surgery.
2. Problem in scheduling diagnostic procedure.
3. Premature admission.
4. Patient dropped from the schedule for any
reason.
5. A weekend.
6. Results of diagnostic tests/procedures or
consultation not yet received.
7. Doing follow-up procedures and/or treatment
that can be done on an outpatient basis.
Sub-Total
II. Postoperative:
1. A weekend.
2. Doing follow-up procedures and/or treatment
that can be done on an outpatient basis.
3. Discharge planned, but no orders written.
4. Lack of family for home care.
Sub-Total
Total

Frequency

Percent

34
2
277

8.74
0.51
71.21

18

4.63

44

11.31

10

2.57

1.03

389

65.16

1.92

157

75.48

14
33
208

6.73
15.87
34.84

597

100

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