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Evaluation of a process of care model for open intravesical ureteral reimplantation from a contemporary healthcare perspective
Pamela Ellsworth, MD, Christi Butler, Medical Student.
Brown University, Providence, RI, USA.

Background: The surgical management of vesicoureteral reflux consists of open and minimally invasive approaches. Open approaches are associated with postoperative hospitalization rates of stay typically 2 to 3 days, varying with the type of procedure, whereas the minimally invasive approachendoscopic correction is a same day procedure. However, overall success rates are lower with the minimally invasive approach endoscopic approach compared to open surgical approaches. Changes in healthcare policy emphasize reduction in cost while maintaining/improving quality of care. We sought to evaluate the impact of a “ one night cost-saving stay process of care” model for open surgical correction of vesicoureteral reflux on quality of care, as defined by return to emergency room or office and/or readmission to the hospital within 2 days of discharge . We compare this length of stay to a contemporary report on rotboticrobotic assisted laparoscopic ureteral reimplantation.
Materials & Methods: An IRB-approved retrospective chart review of all open ureteral reimplantations for vesicoureteral reflux (without any other intravesical bladder procedures, history of prior ureteral reiplantationreimplnatation, or other medical issuescomorbidities which necessitated a prolonged hospitalization) from the January 2009 through January 2013 was performed. Children who underwent ureteral stent placement and those who did not have a caudal anesthetic were excluded from the study. Length of postoperative stay, emergency room records, hospitalizations and office records were reviewed to assess for presentation to the emergency room/office and/or readmission to the hospital within 2 days of discharge from the ureteral reimplantation.
Results: 95 children (17 males, 78 females) underwent open ureteral reimplantation during the 4 year period. Eighty four (88.4%) were discharged on the first postoperative day, 8 (8.4%) on the second postoperative day and 3 (3.2%) on the third postoperative day. Two patients presented to the ER within 2 days of discharge, one in the one night stay group and one in the three night stay group. No child required readmission within 2 days of discharge. Transient ureteral obstruction requiring stent placement occurred in 1 patient (1.05%) 3 days after discharge. Presentation to the ER > 2 days post-discharge was more frequent in those discharged from home POD #1.
Length of stayER presentation with 2 days post dischargeOffice presentation within 2 days post dischargeReadmission within 2 days post dischargePresentation > 2 days post discharge
1 night postoperative
(N=84, 15 male, 69 female)
1002 females presented to ER 3 days after discharge- not admitted
1 female presented to ER 3 days after discharge anuric - stented
1 female presented to office 3 days after discharge
2 nights postoperative
(N= 8, 2 male, 6 female)
0001 female presented to ER 5 days after discharge- admitted for 1 night
3 nights postoperative
(N =3, 3 female)
1000

Conclusions: Optimizing postoperative pain management, earlier catheter removal and preoperative and perioperative parental education allowed us to decrease the length of stay to one night in 84 of the 95 patients (88.4%). A contemporary review on robotic assisted laparoscopic intravesical ureteral reimplantation reported a length of stay of 1.8+ 1.2 days. Thus, this procedural change allowed for a decrease in hospital stay comparable and potentially better than a minimally invasivean endoscopic approach and did not appear to increase the risk of early (within 2 days of discharge) presentation to the ER/office or readmission. ER/office presentations > 2 days after discharge were increased in the POD #1 group, however, the numbers in the other groups are small.


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