Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery

BACKGROUND: Initial programmes of fast-track open colonic surgery with a planned 2-day postoperative hospital stay have had a high readmission rate (about 20 per cent). The aim of this large, consecutive series was to compare readmission rates after a fast-track open colonic surgery programme with a planned hospital stay of 2 versus 3 days. METHODS: The study included 541 consecutive colonic resections from one surgical department with a structured care programme, including well defined discharge criteria, between April 1997 and December 2005. The planned hospital stay was increased from 2 to 3 days from August 2004. All patients were examined 8 and 30 days after surgery. RESULTS: Readmission rates fell from 20.1 per cent in 408 patients with a planned 2-day hospital stay (period 1) to 11.3 per cent in 133 patients with a planned 3-day hospital stay (period 2) (P < 0.020). Median length of primary hospital stay was 2 and 3 days, median stay after readmission was 5 and 5.5 days, and median (mean) total stay was 3 (5.6) and 3 (5.7) days in periods 1 and 2 respectively. The readmission rate in period 2 was lower because there were fewer readmissions for short-term observation or social reasons. There was no difference in type and incidence of morbidity between the two periods. CONCLUSION: Readmission after fast-track open colonic resection was reduced by planning discharge 3 instead of 2 days after surgery, with the same discharge criteria.     

Ileostomy formation does not prolong hospital length of stay after open anterior resection when performed within an enhanced recovery programme

Aim Previous studies have implicated stoma formation as an independent factor prolonging length of stay (LOS) after colorectal surgery. We examined whether loop ileostomy (LI) formation during an open anterior resection affected LOS within a newly developed enhanced recovery programme (ERP). This involved reorganization of services, including stoma care, to optimize pre‐ and perioperative patient education, training and expectation, while applying the standard scientific principles of enhanced recovery. Method Data were collected prospectively on 72 consecutive open anterior resections (33 with LI) to see whether LI affected LOS. Stomas were fashioned at the surgeon’s discretion and patients were discharged according to agreed criteria. Results Thirty‐three of the 72 patients had a covering LI performed. The overall age range was 32–85 years (median 68), with 40 patients being men. LOS for all 72 patients ranged from 3 to 34 days. The median and mean LOS were the same for both groups (median 6 days, mean 8 days). The complication rate was 44% (32/72) with a leak rate of 7% (5/72) and a mortality of 1.4% (1/72). Between the two groups (no ileostomy vs ileostomy), there was no statistically significant difference in complications (41%vs 48%), leakage (8%vs 6%) and readmission rates (12%vs 5%). Conclusion A covering loop ileostomy need not prolong hospital stay after open anterior resection.     

Early rehabilitation after open repair for patients with a rupture of the Achilles tendon

PurposeAs outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation.MethodsMedical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks’ follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks’ follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome.ResultsThe single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p = 0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p = 0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p = 0.042, p = 0.028) between the two groups.ConclusionThe early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery.Type of study / Level of evidence: Therapeutic, Level III.     

Fast-track rehabilitation after open aorto-iliac vascular procedures

BACKGROUND: Fast-track rehabilitation programs have resulted in a decrease in mortality and morbidity after major surgical procedures, e. g., in colorectal surgery. It is not known whether fast-track rehabilitation can safely be applied in major vascular surgery. METHOD: 35 patients (mainly ASA III) who underwent open aorto-iliac reconstruction (21 for abdominal aneurysm, 14 for aorto iliac occlusive disease) between May 2005 and June 2006 were treated with a fast-track protocol including PDA, early postoperative oral fluid and food supply, early postoperative mobilisation, all starting on the day of operation. The average daily oral fluid amount, duration of mobilisation, step of oral nutrition, day of first defecation, PONV, pain levels while resting, under effort and mobilisation, and fatigue were monitored. RESULTS: The 30-day mortality was 0%, overall morbidity was 14.8% with 9% pulmonary, 2.9% cardiac and 2.9% renal complications. Mobility was safely achieved. The oral fluid consumption was 329 mL on the day of operation and 1160 mL on the second day after operation. 33 patients (94%) achieved total oral nutrition on day four after operation. The average pain level in all categories and the fatigue were below 4 on the VAS. CONCLUSION: Fast-track rehabilitation can safely be applied to patients undergoing conventional aorto-iliac reconstruction. Early onset of oral nutrition and mobilisation influence the fatigue in a positive way. Thoracal PDA leads to acceptable pain levels.     

Influences on length of stay in an enhanced recovery programme after colonic surgery

Aim Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. Method Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥4 were excluded. Statistical analyses were performed using the Mann–Whitney U‐test and Cox regression modelling. Results A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right‐sided, 41 left‐sided and two total colectomies. The median age of the patients was 67.5 (range 31–92) years and the median day stay was 4 (range 3–46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high‐dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did. Conclusion Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.     

Update on the risk assessment of a rehabilitation stay for patients after allogeneic stem cell transplantation

ObjectiveHigh-dose chemotherapy with allogeneic stem cell transplantation is the only chance of cure for many haemato-oncological patients. After such therapy, the immune system is weakened, and the contact with other people should therefore be limited as much as possible. The question arises whether a rehabilitation stay can be recommended to these patients, which risk factors for complications during the rehabilitation stay can be identified, and whether physicians and patients can be provided with decision-making aids as to when the optimal time is to start rehabilitation.MethodsWe report about 161 rehabilitation stays of patients after high-dose chemotherapy with allogeneic stem cell transplantation. Premature discontinuation of the rehabilitation was selected as the criterion for a serious complication during the rehabilitation and the underlying reasons were analysed.ResultsThe rate of prematurely terminated rehabilitation stays (13.6%) corresponds to our previous result from 2020. The analysis of the reasons for early termination comes to the conclusion that the rehabilitation stay is only considered as a reason for termination in very few cases, if at all. The risk factors identified for premature termination of the rehabilitation stay were male sex, the period (days) between transplantation and the beginning of the rehabilitation stay, haemoglobin value, platelets and presence of immunosuppressing agent. The most significant risk factor is a decreased platelet count at the time rehabilitation begins. The platelet count, the likelihood that it will improve in the further course and the urgency of the rehabilitation stay can be used to help decide when the optimal time for rehabilitation is given.ConclusionRehabilitation can be recommended to patients after allogeneic stem cell transplantation. Based on various factors, recommendations can be made for the right time for rehabilitation.     

Postoperative care and rehabilitation after open carpal tunnel surgery

Background

Carpal tunnel syndrome is the most commonly diagnosed and treated entrapment neuropathy. The most frequently performed procedure in the surgical treatment is the open release of the flexor retinaculum. Regarding postoperative care, current literature is inconclusive and does not meet the necessary requirements to create a consensus on rehabilitation regimen. Although postoperative splinting is common among hand surgeons and most often applied for 1 week, none of the previous studies have especially assessed the outcome after 7 days of splinting. The aim of this study was to investigate the differences in postoperative rehabilitation following open carpal tunnel release, between a regimen of 1 week dorsal splinting and a light foam bandage for 2 days.

Methods

Sixty patients undergoing carpal tunnel surgery were enrolled in this prospective, noninterventional study. After either receiving a lightweight foam dressing or a splint, patients were followed up at 3 and 6 months, retrieving parameters of pain, two-point discrimination, grip, pinch and keypinch strength, and electrodiagnostic studies.

Results

Significant improvements were observed in both groups, regardless of the respective postoperative care. A comparison of follow-up data between the two study groups did not show any significant differences. Though, statistically significance was detected when comparing grip (5.42 ± 7.35 vs. ?0.19 ± 5.88; p = 0.001) and keypinch strength differences (2.38 ± 5.39 vs. ?0.06 ± 3.30; p = 0.035) at 6 months, favoring nonsplinted individuals.

Conclusions

The results of our research yield little benefit of unrestricted mobility in relation to 1 week postoperative splinting. Immobilization does not entail advantages and thus should be limited to certain circumstances only.     

The effects of a non-operative multimodal programme on osteoarthritis of the knee

INTRODUCTION

The purpose of this study was to determine if a multimodal programme including physiotherapy and education could improve the symptoms of osteoarthritis of the knee across various severities of disease.

PATIENTS AND METHODS

Seventy-two patients with osteoarthritis of the knee confirmed on radiographic evidence were referred over a 13-month period for a lower limb programme which consisted of 12 classes over 6 weeks of group physiotherapy and included education on osteoarthritis, diet and exercise. Six patients went on to have joint arthroplasty at a mean time of 6.5 months with three placed on the waiting list during follow-up.

RESULTS

Pre-intervention, the mean WOMAC score was 42.0 and the mean Oxford Knee Score was 32.8. Post-intervention at a mean follow-up of 12 months, the mean WOMAC score was 31.6 and the mean Oxford Knee Score 24.3. The change in scores following intervention was statistically significant (P < 0.01). Using the WOMAC scoring system, the greatest effect size was seen in patients with Kellgren–Lawrence grade IV whilst using the Oxford knee scoring system, the greatest effect size was seen in patients with Kellgren–Lawrence grade II.

CONCLUSIONS

At 12 months, a multimodal programme of non-operative interventions has an excellent impact upon the symptoms of osteoarthritis of the knee with improved patient-reported scores. The level of improvement cannot be inferred from the radiographic grade of osteoarthritis. This modality could be considered for all patients with mild-to-moderate osteoarthritis of the knee.     

超声引导下连续隐神经阻滞联合多模式镇痛在膝关节置换术中的应用

目的观察超声引导下连续隐神经阻滞(SNB)联合多模式镇痛在膝关节置换术中的应用效果。方法择期行单侧膝关节置换术患者60例,男23例,女37例,年龄50~75岁,采用数字表法随机分为两组:连续隐神经阻滞组(A组)和连续股神经阻滞组(B组)。两组术前均行超声引导,神经阻滞单次给药0.5%罗哌卡因25 ml,置入导管,接镇痛泵持续输入0.2%罗哌卡因。诱导后插入喉罩,术中静-吸复合全麻维持,术毕局部浸润麻醉。记录首次下地时间,行走距离,术后12、24、48 h膝关节活动度及住院天数;记录补救镇痛药物用量及不良反应。结果 A组首次下地时间明显早于B组[(25.4±2.1)h vs(34.0±2.7)h],行走距离明显多于B组[(7.6±1.8)步vs(3.7±1.3)步,P0.05];术后膝关节活动度A组明显大于B组[12 h:(75.8±4.3)°vs(65.4±4.7)°,24 h:(93.3±4.2)°vs(81.8±4.3)°,48 h:(102.1±4.1)°vs(95.1±2.6)°,P0.05];且A组住院时间明显短于B组[(5.3±1.2)d vs(7.4±1.4)d,P0.05];补救镇痛药物及恶心呕吐发生情况两组差异无统计学意义。结论超声引导下连续隐神经阻滞联合多模式镇痛可以促进膝关节置换术后患者早期康复。     

Intensity of rehabilitation and length of stay

This study investigated the effects of different levels of brain injury rehabilitation intensity on length of stay in two hospital-based coma and acute rehabilitation populations. In two hospitals, in separate areas of the USA, rehabilitation intensity was increased from 5h per day to 8h per day, 7 days per week. Patients were studied retrospectively both before and after the change in intensity. There were no significant differences among subjects in age, education, time since injury or level of functioning on admission either across hospitals or from pre- to post-change-in-intensity. Results show that the length of stay significantly decreased 31% for both coma and acute groups in both hospitals. Implications of these findings for clinical treatment and social policy are discussed.     

Evaluating the effectiveness of a patient-oriented hand rehabilitation programme

This study evaluated the effectiveness of a patient-oriented, hand rehabilitation programme compared to a standard programme regarding functional outcomes, return to work, patient satisfaction and costs. Patients were recruited in two consecutive cohorts. One cohort received the standard treatment programme (n = 75) and the other a programme based on principles of patient orientation (n = 75). Data were collected at the beginning and end of rehabilitation and 6 months after discharge. Clinical variables included range of motion, grip and pinch strength. Self-reported measures included pain, upper extremity functioning, health status, satisfaction and job situation. Analysis of variance for repeated measurements was used to calculate the main effects. The patient-oriented group showed more favourable results with respect to DASH scores (P <.05), pain (P <.001) and patient satisfaction (P <.0001). More patients returned to their former jobs and time off sick was reduced. We concluded that the patient-oriented approach was more effective and cost-saving.     

Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement

Background Because of current cost restrictions, we studied the effect of a shorter hospital stay on function, pain and quality of life (QOL) after total hip replacement (THR).

Patients and methods 50 patients from two hospitals were randomized into a study group (SG) of 27 patients receiving preoperative and postoperative education programs, as well as home visits from an outpatient team, and a control group (CG) of 23 patients receiving “conventional” rehabilitation often augmented by a stay at a rehabilitation center.

Results Mean hospital stay was shorter for the SG than for the CG (6.4 days and 10 days, respectively; p < 0.001). During the 6-month study period, there were 9 non-fatal complications in the SG and 12 in the CG (p = 0.3). The difference in Oxford Hip Score between the groups was not statistically significant before the operation, but was better for the SG at 2 months (p = 0.03) and this difference remained more or less constant throughout the study. The overall score from the Nottingham Health Profile indicated a better QOL in the SG.

Interpretation Our preoperative education program, followed by postoperative home-based rehabilitation, appears to be safer and more effective in improving function and QOL after THR than conventional treatment.