Ambulatory laparoscopic cholecystectomy is as effective as hospitalization and from a social perspective less expensive: a randomized study]

OBJECTIVE: To compare the effects and costs of an ambulatory treatment versus an overnight stay for laparoscopic cholecystectomy. DESIGN: Prospective, randomised. METHOD: In the St Antonius hospital, Nieuwegein, the Netherlands, 86 patients with symptomatic cholelithiasis without comorbidity underwent either ambulatory (AM: 42 patients: 8 men and 36 women; mean age: 48.9 years (SD: 11.9)) or overnight stay (OS: 44 patients: 10 men and 32 women; mean age: 44.9 years (SD: 11.8)) laparoscopic cholecystectomy in the period 1 November 1997-30 September 1999. The following were registered: operative time, complications, hospital stay and readmissions, as well as reported pain, nausea, activity resumption, quality of life and patient satisfaction. The cost analysis was performed from a societal and hospital perspective. RESULTS: In the OS group one laparoscopic procedure was converted to open cholecystectomy, two relaparotomies were performed due to intra-abdominal haemorrhage and 1 patient had a catheter inserted due to urine retention. Two patients were readmitted, one for postoperative pancreatitis and the other for a retained bile duct stone. In the AM group one laparoscopic procedure was converted to open cholecystectomy, in 1 patient a wound abscess was treated with drainage in the outpatient clinic, in 1 patient there was peroperative stone loss without further complications and in 1 patient a catheter was placed to drain peroperative bile and blood loss. In the AM group 11 (26%) patients were kept overnight due to nausea and/or pain (n = 7) or one of the aforementioned complications (n = 4). Two patients were readmitted within 24 hours of being discharged due to abdominal pain. The average hospital stay was 3.1 (OS) versus 1.7 (AM) days. The quality of life, pain, nausea and activity resumption were comparable for both groups. Due to the difference in hospital stay, costs for the ambulatory procedure were lower. CONCLUSION: Laparoscopic cholecystectomy was successfully performed as an ambulatory surgery procedure in 69% of the patients. The quality of life, patient satisfaction and resumption of activities in both groups were comparable. The ambulatory treatment was less expensive.     

Home monitoring of blood pressure: usefulness as a predictor of persistent hypertension

We set out to test the hypothesis that home blood pressure reflects "baseline" pressures measured at a general practitioner's surgery or in a hospital outpatient clinic. Twenty patients detected hypertensive during screening in general practice and 30 patients referred to a hospital hypertension clinic for revision of therapy were studied. All were instructed in the use of an electronic semiautomatic sphygmomanometer and measured blood pressure at home for a three day period. Home monitored blood pressure correctly predicted those patients whose diastolic blood pressure fell to below 95 mmHg by the third clinic visit in approximately 90% of all patients. In addition, in those whose blood pressure was high at home it remained so at the clinic or surgery after three visits. These data suggest that home monitoring of blood pressure may be a helpful alternative to repeated clinic visits before embarking on medical therapy.     

Serious haemorrhage after conventional (adeno)tonsillectomy: rare and most often on the day of the procedure

OBJECTIVE: To analyse the incidence and timing of postoperative haemorrhage that requires re-operation following tonsillectomy or adenotonsillectomy, and to formulate a recommendation regarding the optimal duration of postoperative clinical observation. DESIGN: Retrospective. METHOD: Data were collected on the incidence of haemorrhage that required exploratory surgery in all patients who underwent adenotomy (n=3508) or tonsillectomy or adenotonsillectomy (n=4909) in the period 1996-2002 at the Sint Lucas Andreas Hospital in Amsterdam, the Netherlands. The Sluder technique was used on an outpatient basis in 2439 of the 4909 patients who underwent tonsillectomy or adenotonsillectomy; these patients were aged <10 years. The remaining 2470 patients were aged > or =10 years and underwent conventional dissection followed by 24 hours of clinical observation before being discharged. RESULTS: Postoperative haemorrhage was recorded in 0 of the 3508 patients who underwent adenotomy, 12 (0.5%) of the 2439 patients aged <10 years who underwent tonsillectomy using the Sluder technique and 43 (1.7%) of the 2470 patient aged > or =10 years who underwent conventional dissection. Of the 43 cases of haemorrhage after conventional dissection, 31 (75%) occurred within 24 hours, including 2 cases that occurred between 12 and 24 hours (2/2470; 0.08%; 95% CI: 0.001-0.29). CONCLUSION: Reducing the postoperative observation period from 24 hours to 12 hours would have unfavourable consequences in 1 (95% CI: 0-3) per 1ooo patients operated. In regard to the risk of postoperative haemorrhage, outpatient tonsillectomy and adenotonsillectomy appear to be justified for patients aged 10 years or over, provided that surgery is performed in the morning and the patient is observed in a ward that is open until the evening.     

An analysis of decision making in discharge planning

A repeated-measures design was used to examine medical professionals' discharge planning strategies. Physicians, residents, nurses, and social workers were presented with 16 hypothetical case scenarios and asked to: (1) rate the appropriateness of four discharge options (nursing home, community nursing, adult day, and outpatient clinic care), and (2) select the most appropriate discharge plan for each case. Four within-group variables were included in the scenarios: physical impairment, caregiver availability, follow-up required, and patient compliance. Decisions were greatly influenced by caregiver availability. When a caregiver was available, respondents preferred community-based options (i.e., community nursing care or outpatient clinic); if the case involved complications (i.e., severe physical impairment, heavy follow-up, noncompliant patient), they considered community nursing care more appropriate than outpatient clinic. When a caregiver was unavailable, respondents preferred institution-based options (i.e., nursing home or adult daycare); if there were complications, they considered nursing home more appropriate than adult daycare.     

Same-day diathermic hemorrhoidectomy in 48 patients; few complications and tolerable pain

OBJECT: To measure pain characteristics and to ascertain patient satisfaction and level of complications after day-care haemorrhoidectomy. DESIGN: Prospective. METHOD: Diathermic haemorrhoidectomy was performed in daytime care in 40 successive patients in hospital De Heel, Zaandam in 1997-1998. The operation was part of a package of measures, such as extensive counseling, preoperative bulking agents, surgery performed by colorectal surgeon, dedicated anaesthesiological techniques, adequate pain medication, and frequent outpatient clinic visits. RESULTS: The 40 patients were 21 men and 19 women with a mean age of 43 years (range: 27-67). One male patient was admitted for 24 hours because of urinary retention and 1 female patient developed a wound infection. No other serious complications were seen. During the first 5 postoperative bowel movements 75% of the total pain score was obtained. Postdefaecatory pain lasted on average 81 min on day 1 to 8 min on day 7. Time away from work was on average 6.4 days (range: 0-12). In between clinic visits 5 patients consulted their general practitioners. After 6 weeks 95% of the patients would again have consented to day-care haemorrhoidectomy. CONCLUSION: Diathermic haemorrhoidectomy has a low complication rate and tolerable pain and can be performed in day care.     

Nurse practitioner equally as good as a resident in the treatment of stable patients after recent myocardial infarction, but with more patient satisfaction

OBJECTIVE: To determine the feasibility and efficacy ofa nurse-led clinic for stable patients recovering from a recent myocardial infarction, as opposed to a resident-led clinic. DESIGN: Randomized study. METHOD: Over a period of 1 year, data on the treatment and complications of 200 consecutive infarction patients were collected. The patients were randomized on transfer from the coronary-care unit to the cardiology ward. Subsequently, these patients were treated by a registered nurse practitioner (n = 97) or by a resident (n = 103), both of whom were under the direct supervision of the attending cardiologist. Degree of satisfaction was scored by the patients on a 0-10 point scale. RESULTS: The patients in both groups were predominantly men (75%) with a mean age of 63 years. Risk factors and cardiac histories were comparable in both groups as were the location of the infarction and the nature of the acute treatment. No significant differences between the groups were found in the main endpoints: mortality (0%), re-infarctions (2%) or length ofstay. However, patients treated by the nurse practitioner expressed a significantly higher score in the satisfaction study. CONCLUSION: The treatment of stable postmyocardial infarction patients in a nurse-practitioner-led clinic post was found to be feasible and effective with a significantly higher level of patient satisfaction.     

Monitoring of patients on home parenteral nutrition (HPN) in Europe: a questionnaire based study on monitoring practice in 42 centres

INTRODUCTION & AIM: To gather information about how adult patients on home parenteral nutrition (HPN) are monitored after discharge from the hospital. METHOD: A questionnaire about HPN monitoring practice was circulated to HPN centres in eight European countries through the representative of the ESPEN HAN-working group. Centres were asked about guidelines, home visits and how monitoring and handling of complications were managed. RESULTS: Fourty-two centres in eight European countries completed the questionnaire: UK n=14, France n=9, Belgium n=4, Italy n=4, Poland n=4, Denmark n=4, Spain n=2, Germany n=1. The HPN experience of the centres was in the range 2-30 years. Centres ranged in size from 0 to 125 HPN patients representing a total number of 934 of whom 54% had received HPN for more than 2 years. The primary disease was non-malignant in 90% whilst 10% had been diagnosed with active cancer. Of the centres 92% had a HPN team and 66% had written guidelines for monitoring HPN. Home visits after discharge for monitoring purposes were carried out by 31 of the centres involving the HPN team, general practitioner, community nurse or home care agency. Stable patients on HPN for more than 12 months were monitored at the discharging hospital (73%), at a local hospital (12%), by the General Practitioner (11%) or by a home care agency (4%). Of the centres, 90% reported that the main responsibility for monitoring was assigned to a specific person. The intervals between monitoring visits for the stable HPN patient was in the range 1-6 months, 52% of the centres reported intervals of 2-3 months. In case of complications 76% of centres reported that patients got in touch with the HPN team, 2% the local hospital, 5% the home care agency, and 17% other. Re-admission to hospital was usually to the HPN centre and only occasionally to a local hospital. CONCLUSION: In Europe a specialised team at the discharging hospital monitors HPN patients and 66% of the centres had some kind of written guidelines.     

Home care for patients with cancer]

A report of the Health Council of the Netherlands concerning home care for patients with cancer contains conditions required for the shift from hospital care to home care, but securing the maintainance of the quality of care. A new style of oncology outpatient clinic is proposed, which enables the general practitioner to provide for consultation tailored to the needs of these particular patients. This proposal has organizational and financial consequences.     

Improving the quality of outpatient clinic letters using the Sheffield Assessment Instrument for Letters (SAIL)

AIM: To improve the quality of outpatient letters used as communication between hospital and primary care doctors. METHODS: On 2 separate occasions, 15 unselected outpatient letters written by each of 7 hospital practitioners were rated by another hospital doctor and a general practitioner (GP) using the Sheffield Assessment Instrument for Letters (SAIL). Individualised feedback was provided to participants following the rating of the first set of letters. The audit cycle was completed 3 months later without forewarning by repeat assessment by the same hospital and GP assessors using the SAIL tool to see if there was any improvement in correspondence. SETTING: Single centre: general paediatric outpatient department in a large district general hospital. RESULTS: All 7 doctors available for reassessment completed the audit loop, each providing 15 outpatient letters per assessment. The mean of the quality scores, derived for each letter from the summation of a 20-point checklist and a global score, improved from 23.3 (95% CI 22.1-24.4) to 26.6 (95% CI 25.8-27.4) (P = 0.001). CONCLUSIONS: The SAIL provides a feasible and reliable method of assessing the quality and content of outpatient clinic letters. This study demonstrates that it can also provide feedback with a powerful educational impact. This approach holds real potential for appraisal and revalidation, providing an effective means for the quality improvement required by clinical governance.     

The use of complementary and alternative medicine in children at a general paediatric clinic and parental reasons for use

OBJECTIVE: To determine the prevalence of and reasons for the use of complementary and alternative medicine (CAM) in paediatric patients, and to determine the parental need for appropriate information from their paediatrician. DESIGN: Questionnaire. METHOD: A questionnaire was given to the parents of general paediatric patients of the St. Antonius Hospital Nieuwegein and the University Medical Centre Utrecht, the Netherlands, in the period June 2003-March 2004. Parents were asked about CAM use in the past 12 months, which CAM modalities were used and their reasons for using it. They were also asked about their need to receive information on CAM from their paediatrician. RESULTS: A total of 581 of 617 parents completed the questionnaire (94%). CAM was used by 177 (30%) patients. The most frequently used types of CAM were homeopathy (48%), phytotherapy (45%), nutritional supplements (28%) and manual therapies (28%). CAM was used most often in children with headache or chronic fatigue. The most frequently cited reasons for CAM use were a desire for the child to feel better and a preference for a 'more natural' therapy. Factors associated with CAM use were a high level of parental education and use of CAM by the parent. Only 40% of parents had reported the use of CAM to their paediatrician, usually on their own initiative. The majority of the parents (60%) found it important to very important that the paediatrician is able to provide information on CAM. CONCLUSION: Almost one-third of patients visiting a general paediatrician had used complementary or alternative medicine in the past year. Given the possible interactions with conventional therapies and the desire of parents to receive more information on CAM, paediatricians should expand the patient history assessment to include questions regarding the use of CAM.     

Favourable long-term results using the unmodified maze procedure in patients with medication-refractory or nearly refractory atrial fibrillation; experience from 1993/'04

OBJECTIVE: To assess the short- and long-term results following the unmodified maze procedure in patients with medication-refractory or nearly refractory atrial fibrillation. DESIGN: Retrospective. METHODS: We retrospectively collected and analysed preoperatively in-hospital and follow-up data from patients with atrial fibrillation with or without structural heart disease who underwent the unmodified maze procedure in the St. Antonius hospital, Nieuwegein, the Netherlands. RESULTS: In the 11-year period 1993-2004, 203 patients underwent the procedure: 139 underwent the maze procedure only and 64 underwent combined surgery for concomitant atrial fibrillation and structural heart disease. There were no in-hospital deaths. During a mean follow-up period of 4 years, 2 ofthe 203 patients died from cardiac causes; both had undergone combined surgery. With a mean follow-up period of 4 years, the rate of atrial fibrillation-free survival was 90% in patients with lone atrial fibrillation and 70% in patients with concomitant atrial fibrillation. For patients who had no recurrent atrial fibrillation 1 year after surgery, the risk of recurrence after 4 years was small (odds ratio: 9.56). Risk factors for recurrence included a large left atrium and a long duration of atrial fibrillation (more than 5 years). CONCLUSION: The maze procedure was a successful surgical intervention for patients with atrial fibrillation, both in the short and long term. This procedure can be considered when medication and electrical cardioversion are ineffective.     

The effect of telephone reminders on attendance in respiratory outpatient clinics

INTRODUCTION: Patient non-attendance is an area of concern for all health care providers. A randomized controlled trial was undertaken to investigate whether reminder telephone calls improved attendance at respiratory outpatient clinics in the English National Health Service (NHS). METHODS: Patients were randomly allocated into one of two groups, either telephone reminder group or usual care. The telephone reminder group received a reminder telephone call between 9 am and 5 pm during the week prior to their appointment. Attendance and demographic information (age, sex, diagnosis and home postcode) were recorded. RESULTS: A total of 504 patients were recruited, 258 patients were allocated to the control group and 246 patients were allocated to the telephone reminder group. Fifty-eight percent of the patients allocated to the telephone reminder group were not contactable. Within the telephone reminder group, of the 104 patients who could be contacted, 86% attended. There was a significant 15% increase in attendance in the contacted group (n = 104) when compared both with the control group (71%, n = 258) and with the patients who could not be contacted (68%, n = 142) (P = 0.007; P = 0.004). It was estimated that the cost of telephoning 200 patients could be offset by preventing one non-attendance. CONCLUSION: Routine telephoning of outpatients should become standard practice if reducing non-attendance is thought to be desirable, but general practitioner (GP) referral letters and hospital records of current hospital outpatients need to include an up-to-date telephone number. Consideration should be given to 'out-of-hours' reminder calls to maximize the contact rate.     

A confidential enquiry into emergency hospital admissions on the Isle of Wight, UK.

OBJECTIVES: To quantify the proportion of potentially avoidable emergency short term admissions to hospital and to identify ways in which they could have been avoided. DESIGN: Confidential enquiry by peer review group. SETTING: St Mary's Hospital, Newport, Isle of Wight. SUBJECTS: All emergency, short term admissions (discharged home within five days) to medicine, general surgery, orthopaedics, gynaecology, ENT, and ophthalmology specialties for 28 (24 hour) days over a six month period in 1994. MAIN OUTCOME MEASURES: Appropriateness of admissions decided by the peer group, the peer group's opinion of ideal management, and the patients' views on the appropriateness of their admission. RESULTS: Altogether 139 cases satisfied the inclusion criteria. Complete data were collected on 123 cases and the peer group considered 81 in the time available. Twenty one of the 81 cases were judged "potentially avoidable". These represent 9.5% (95% CI 6.3%, 13.5%) of short term admissions to the specialties studied. The peer group considered that seven of 10 patients referred by a general practitioner (GP) could have been managed by the GP alone and that the remaining three had been referred appropriately but need not have been admitted had a consultant opinion been available in the accident and emergency (A&E) department. Two of the 10 would have required home support to avoid hospital admission. Five of 11 patients who referred themselves to A&E could have been discharged home without admission and without recourse to a specialist opinion. The remaining six could have been discharged had a consultant opinion been available in A&E. CONCLUSIONS: Urgent consultant opinion, either in A&E or in an outpatient clinic, would have prevented most of these inappropriate admissions, and home support would have expedited the ability to discharge some patients. Further research into the costs and benefits of methods for providing these services is needed urgently.     

Care of non-severe acute diarrhea in infants: a socioeconomic approach

During a period of 3 months, 267 children with non severe acute diarrhea (NSAD) were treated by one of four modalities of care: in the private office of a general practitioner (n = 58), or of a paediatrician (n = 109), in a hospital emergency service (n = 62), or as hospital inpatients (n = 38). The socio-economic status and the cost of treatment for each of these children was subsequently assessed. The children admitted to hospital were mainly referred by hospital out-patient departments (47%) and general practitioners (37%) who, unlike paediatricians, care for more socially disadvantaged patients. The main reason for hospitalization was the presence of diarrhea with vomiting (55%). Several measures are proposed to redefine the role of the hospital and to improve cooperation with doctors in office practice, which would reduce both the number of hospitalizations due to NSAD and the length of hospital stay. Since the cost of treating NSAD hospital is 60 time greater than care at home, these measures are economically important.     

Comparative study of surgical wound infection diagnosed in-hospital and post discharge

OBJECTIVE: Surgical wound infection (SWI) is a serious hospital infection due to its incidence, morbidity and mortality. Because of the short hospital stay, the majority of SWI appears post-discharge, and its incidence is often underreported when there is no follow-up of the surgical patient post discharge. The need of a surveillance system for surgical patient after discharge is critical for infection control. The study objective was to determine the incidence of SWI in surgical patients and to compare the frequency of SWI diagnosed in-hospital and after discharge. METHODS: A prospective cohort study was carried out in a university hospital. Patients admitted to the general surgery unit (504) and underwent digestive tract surgery in the first semester of the year 2000 were followed up during their hospital stay and after discharge. RESULTS: Of 504 surgical patients, 398 (79.0%) returned to follow up in the post discharge outpatient clinic. Of the total surgical wound infections diagnosed, most (62.9%) was detected in the post discharge outpatient clinic, and 88% of SWI diagnosed were classified as superficial, and 67% reported up to day 7 after discharge. CONCLUSIONS: This study showed the importance of following up surgical patients after discharge to achieve reliable incidence data on surgical wound infection because of the late occurrence of infection in the majority of cases, which results in underreporting when the patient is followed up only during the hospital stay.