Factors predicting prolonged length of stay after carotid endarterectomy

BACKGROUND: Over the last several years, implementation of critical pathways in patients undergoing carotid endarterectomy has decreased postoperative length of stay significantly. Discharge the day after surgery has become commonplace in many centers, including our own. Unfortunately, managed care may interpret this refinement as a standard of care and limit reimbursement or even disallow admissions extending beyond 1 day. We therefore examined our carotid registry to identify risk factors associated with postoperative length of stay exceeding 1 day. METHODS: We retrospectively reviewed all patients undergoing carotid endarterectomy at our academic center from May 1996 through April 1999. Combined procedures and patients undergoing subsequent noncarotid-related procedures on those admissions were excluded. The charts were inspected for atherosclerosis risk factors, including sex and age, specific attending surgeon, side of the surgery, use of intravenous vasoactive drugs, actual preoperative blood pressure, and presence of neurologic symptoms or postoperative complications. Multiple regression analysis was performed on all collected variables. Statistical significance was inferred for P less than.05. RESULTS: A total of 188 patients met the study criteria and had complete, retrievable medical records. A mean postoperative length of stay of 1.65 +/- 0.08 days and a mean total length of stay of 2.17 +/- 0.14 days were observed. Fifty-seven percent of patients went home the day after surgery. There was a 1.6% stroke-mortality rate. Significant predictors of a prolonged stay, listed in order of decreasing importance on the basis of their calculated contribution to prolonging the postoperative length of stay, are as follows (P value; beta coefficient): postoperative complications (<.0001; 1.03), age > 79 years (.008; 0.547), diabetes mellitus (.011; 0.407), female sex (.007; 0.398), and intravenous vasodilator requirement (. 035; 0.382). Other atherosclerosis risk factors, prior neurologic symptoms, the postoperative use of vasopressors, and reoperative surgery did not contribute to extended length of stay. CONCLUSIONS: Discharge on the first postoperative day is feasible in many, but not all, patients undergoing carotid endarterectomy. Our data help define subsets of patients at risk for prolonged postoperative stay. Targeting these subsets for preoperative medical and social interventions may allow safe early discharge more frequently.     

Factors contributing to a prolonged stay after ambulatory surgery

We identified predictors for prolonged postoperative stay after ambulatory surgery using multiple logistic regression models. We collected perioperative data for 16,411 ambulatory surgical patients. A log-transformed time to discharge variable was modeled by multiple linear regression, including patient-, anesthesia-, and surgery-specific variables. The impact of hypothetical elimination of perioperative adverse events on mean length of stay was also estimated. Separate analyses were performed among patients who received general anesthesia (GA) and monitored anesthesia care (MAC). Patients receiving GA stayed 50 min longer than patients receiving MAC. Patients receiving GA and undergoing strabismus, transurethral, or otorhinolaryngological/dental procedures had the longest postoperative stay. Among patients receiving GA, smokers had a 4% shorter stay compared with nonsmokers; among patients receiving MAC, those with congestive heart failure (CHF) had a 11% longer stay compared with patients without CHF. Postoperative nausea and vomiting, dizziness, excessive pain, and cardiovascular events predicted 22%-79% increases in postoperative stay. The hypothetical elimination of all adverse events resulted in a 9.6% decrease in mean length of stay among patients receiving GA, but in only a 3.8% decrease among patients receiving MAC. The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and cardiovascular events. Patients with CHF and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving GA. IMPLICATIONS: The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.     

Factors that influence length of stay after appendicectomy in children

BACKGROUND: The length of hospital stay following appendicectomy in children at Christchurch Hospital has decreased in recent years. The aim of the present study was to identify those factors that contributed to this change. METHODS: A retrospective review of children admitted to Christchurch Hospital between 1994 and 1998 inclusive who underwent appendicectomy for suspected appendicitis was conducted. Data recorded included standard demographic information, symptom duration, operative details, analgesia, antibiotics, pathology, complications and postoperative length of stay (LOS). RESULTS: Postoperative LOS decreased significantly during the period reviewed across all degrees of appendiceal inflammation, from a mean of 70.5 to 50.1 h. The main determinant of postoperative hospital stay was the severity of the appendiceal inflammatory process. Other factors that influenced LOS included surgical approach (open vs. laparoscopic), use of intra-operative local anaesthesia, type and mode of postoperative analgesia, and age of the child. Longer duration of antibiotic use and symptom duration of greater than 24 h were associated with a longer LOS, primarily as a reflection of the severity of inflammation of the appendix. Factors that appeared to have little or no influence included gender and the experience of the surgeon. CONCLUSION: The severity of the inflammatory process appeared to be the main determinant of postoperative hospital LOS; advanced appendicitis with abscess formation or peritonitis was associated with the longest LOS, irrespective of the surgical approach, although the LOS after appendicectomy was reduced by a laparoscopic approach. Intra-operative local anaesthesia during open appendicectomy reduced hospital stay, probably because it reduced the need for postoperative narcotics. Early diagnosis (< 24 h) was associated with a shorter postoperative LOS for acutely inflamed appendices.     

Preoperative factors that predict hospital length of stay after distal arterial bypass

Purpose: The purpose of this study was to identify the preoperative factors that are predictive of prolonged hospital length of stay (LOS) and to discuss strategies that might assist in minimizing LOS for this select group of patients.Methods: Two hundred seventy-five arterial bypass procedures with the in situ technique were performed between 1986 and 1993. The relationship between 14 preoperative variables and hospital LOS was analyzed with both univariate (Kaplan-Meier) and multivariate (Cox regression) statistical techniques. A model was developed to determine the significant preoperative variables that were associated with prolonged LOS.Results: The primary and secondary patency rates and limb salvage rates at 4 years were 73.3% ± 3.2%, 78.9% ± 2.9%, and 81.9% ± 3.2%, respectively. The median postoperative LOS was 15 days, with a mean ± SD of 17.8 ± 12.3 days (range 4 to 93 days). With Cox regression analysis, the variables that were significant predictors of LOS (with a model p value < 0.002) were age (greater than 74 years vs less than 75), history of cerebrovascular disease (transient ischemic attack, stroke, past carotid endarterectomy vs nil), and operative indication (limb salvage vs disabling claudication).Conclusions: This study illustrates that certain preoperative variables are predictive of prolonged postoperative LOS after in situ bypass. The significant preoperative factors identified should be used to direct specific care and discharge planning for these individuals. (J V ASC S URG 1994;20:70-5.)     

Medicare and Medicaid status predicts prolonged length of stay after bariatric surgery

BACKGROUND: The outcomes of Medicare patients undergoing bariatric surgery have been particularly scrutinized, especially with the Center of Medicare and Medicaid Services' decision to offer bariatric surgery benefits. METHODS: The length-of-stay (LOS) data were analyzed from the National Hospital Discharge Survey from 2002 to 2004. To test the hypothesis that Medicare and Medicaid beneficiaries were more likely to have a prolonged length of stay (PLOS), we used a multivariate logistic regression model controlling for age, gender, hospital size, and year of procedure. RESULTS: An estimated 312,000 bariatric procedures were performed nationally from 2002 to 2004. The average patient age was 41.5 years (range 14-75) and 83.6% were women. The in-hospital mortality rate was reported to be .17%. A PLOS occurred in 3.7% of the population. The Medicare and Medicaid beneficiaries represented 5.7% and 6.2% of the population, respectively. The Medicare beneficiaries were 6.0 times (95% confidence interval 2.5-14; P <.001) as likely to have a PLOS, and Medicaid beneficiaries were 3.2 times (95% confidence interval 1.2-8.9; P = .02) as likely to have a PLOS as others after controlling for age, gender, hospital size, and year of procedure. For every 10-year increase in age, the risk of a PLOS increased by 30% (P <.012). CONCLUSION: Medicare and Medicaid beneficiaries are both at an increased risk of a PLOS. This study was not designed to identify the potential causes of a PLOS. Data from prospectively collected bariatric registries might aid surgeons in assessing the risk/benefit ratio of surgical interventions in groups regarded as high risk.     

Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A

BACKGROUND: Operative mortality after acute aortic dissection type A is still high, and prolonged stay at the intensive care unit is common. Little has been documented about factors influencing the intensive care unit length of stay. The aim of this study was to determine such variables. METHODS: During a 10-year period, 67 patients (47 male, 20 female) were operated on for acute aortic dissection type A. In 42 patients (63%), an ascending aortic replacement was performed, 23 patients (34%) underwent a Bentall procedure, and 2 patients (3%) received a valve-sparing David type of operation. In 14 of these cases (20%), an additional partial or total arch replacement was performed. RESULTS: Hospital mortality was 9 of 67 (14%). Median postoperative intensive care unit length of stay was 5 days (range, 1 to 72 days). Intensive care unit stay was in univariate analysis significantly influenced by the following factors: age (p = 0.008), body mass index (p = 0.039), cardiopulmonary bypass time (p = 0.018), aortic cross-clamp time (p = 0.031), postoperative low cardiac output syndrome (p < 0.001), and postoperative lactate levels (p = 0.01). By multivariate analysis, age (p = 0.012), cardiopulmonary bypass time (p = 0.037), and the presence of a postoperative low cardiac output syndrome (p < 0.001) significantly influenced intensive care unit stay. CONCLUSIONS: Stay in the intensive care unit after operation for acute aortic dissection type A seems to be determined by age, cardiopulmonary bypass time, and the postoperative presence of a low cardiac output syndrome.     

Factors influencing postoperative length of hospital stay after breast cancer surgery

As part of a feasibility study to restructure the breast cancer services in Glasgow, factors influencing ‘postoperative length of stay’ (LOS) and bed utilisation in patients undergoing surgery for breast cancer were examined.Data for patients admitted at five hospitals between March 2007 and February 2008 was collected prospectively. Age, socio-demographic and clinico-pathologic factors were recorded. Independent affects of variables predicting prolonged LOS were assessed using binary logistic regression analysis.Of the 519 women, 252(49%) had screen-detected cancers with a median LOS of 1 day while 267(51%) had symptomatic cancers with a median LOS of 4 days (p < 0.001). On multivariate analysis, axillary procedure performed independently influenced prolonged LOS in both screen-detected and symptomatic cancers. In symptomatic cancers, comorbidities and deprivation also had some influence. While mastectomy with or without axillary surgery utilised 51% of the bed days, a further 20% were utilised by patients having re-operations.This study has helped in the planning of ambulatory surgery services and inpatient bed requirements for patients undergoing breast cancer surgery in Glasgow.     

Does EuroSCORE predict length of stay and specific postoperative complications after cardiac surgery?

OBJECTIVE: To evaluate the performance of EuroSCORE in the prediction of in-hospital postoperative length of stay and specific major postoperative complications after cardiac surgery. METHODS: Data on 5051 consecutive patients (isolated [74.4%] or combined coronary artery bypass grafting [11.1%], valve surgery [12.0%] and thoracic aortic surgery [2.5%]) were prospectively collected. The EuroSCORE model (standard and logistic) was used to predict in-hospital mortality, 3-month mortality, prolonged length of stay (>12 days) and major postoperative complications (intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, re-exploration for bleeding, sepsis and/or endocarditis, gastrointestinal complications, postoperative renal failure and respiratory failure). A C statistic (or the area under the receiver operating characteristic curve) was used to test the discrimination of the EuroSCORE. The calibration of the model was assessed by the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: In-hospital mortality was 3.9% and 16.1% of patients had one or more major complications. Standard EuroSCORE showed very good discriminatory ability and good calibration in predicting in-hospital mortality (C statistic: 0.76, Hosmer-Lemeshow: P=0.449) and postoperative renal failure (C statistic: 0.79, Hosmer-Lemeshow: P=0.089) and good discriminatory ability in predicting sepsis and/or endocarditis (C statistic: 0.74, Hosmer-Lemeshow: P=0.653), 3-month mortality (C statistic: 0.73, Hosmer-Lemeshow: P=0.097), prolonged length of stay (C statistic: 0.71, Hosmer-Lemeshow: P=0.051) and respiratory failure (C statistic: 0.71, Hosmer-Lemeshow: P=0.714). There were no differences in terms of the discriminatory ability in predicting these outcomes between standard and logistic EuroSCORE. However, logistic EuroSCORE showed no calibration (Hosmer-Lemeshow: P<0.05) except for sepsis and/or endocarditis (Hosmer-Lemeshow: P=0.078). EuroSCORE was unable to predict other major complications such as intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, gastrointestinal complications and re-exploration for bleeding. CONCLUSIONS: EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also 3-month mortality, prolonged length of stay and specific postoperative complications such as renal failure, sepsis and/or endocarditis and respiratory failure in the whole context of cardiac surgery. These outcomes can be predicted accurately using the standard EuroSCORE which is very simple and easy in its calculation.     

胰腺神经内分泌肿瘤患者腹腔镜术后住院时间延长的危险因素分析

目的 探究胰腺神经内分泌肿瘤（pNETs）患者行腹腔镜手术后住院时间延长的危险因素。方法 回顾性分析2015年1月至2022年8月在浙江省人民医院行腹腔镜手术治疗的91例pNETs患者的临床资料。以术后住院时间是否超过中位住院时间12 d将患者分为住院时间正常组（NLOS组,≤12 d,n=50）和住院时间延长组（PLOS组,>12 d,n=41）。通过单因素和多因素Logistic回归分析患者术后住院时间延长的危险因素,用AUC和Brier分数评价区分度和校准度。结果 单因素及多因素分析显示,手术时间>210 min(OR=8.850,95%CI 2.699～29.013,P<0.001)和腹腔镜手术方式[腹腔镜胰十二指肠切除术（LPD）:OR=5.753,95%CI 1.062～31.155,P=0.042;腹腔镜胰腺体尾切除术（LDP:OR=8.547,95%CI1.908～38.291,P=0.005]是患者住院时间延长的独立危险因素。此时相应的AUC为0.785,Brier分数为0.182。结论 手术时间和手术方式是预测pNETs患者腹腔镜术后住院时间是否延...     

Determinants of hospital length of stay after thoracoabdominal aortic aneurysm repair

PURPOSE: Extended hospital length of stay (LOS) and consequent high costs are associated with thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery. In this study, we examined factors that may influence LOS after TAAA repair. METHODS: Five hundred forty thoracic and TAAA repairs were performed by one surgeon between 1990 and 1999. The data were analyzed with multiple linear regression with appropriate logarithmic transformation. The predictor variables included patient demographics, disease extent, severity indicators, intraoperative factors, and postoperative complications. RESULTS: The median LOS was 15 days. Postoperative creatinine level of greater than 2.9 was the most important predictor of LOS, followed by spinal cord deficit, age, and pulmonary complication (all statistically significant with P <.05). A second model constrained to preoperative risk factors showed both age and complete diaphragmatic division to be associated with increased LOS. Preservation of the diaphragm led to reduced LOS by an average of 4 days. The adjunct cerebrospinal fluid drainage and distal aortic perfusion was associated with a decrease in LOS, although it did not reach statistical significance. CONCLUSION: Renal failure, spinal cord deficit, and pulmonary complication were the major determinants of LOS in patients for TAAA repair. This study shows that the preservation of diaphragmatic function and the use of the adjunct distal aortic perfusion and cerebrospinal fluid drainage may reduce hospital LOS.     

Factors related to short length of stay after carotid endarterectomy

In the past decade, expected in-hospital length of stay (LOS) after carotid endarterectomy (CEA) has decreased from 4 days to 1. Long LOS is associated with known complications and factors affecting severity of the patient's condition. Factors affecting an intermediate stay of 2 to 4 days need further clarification. The vascular registry at Jobst Vascular Center includes data on manifestation of disease; cardiovascular history; operation and discharge dates; surgeon; surgical details such as patching, shunting, and completion arteriography; and complications. Univariate chi-square and ANOVA and multivariate logistic regression were applied to analyze 635 CEAs performed in 1998, 1999, and 2000. Statistical significance was at a p value less than 0.05 (two-sided). Overall morbidity rate was 8.2% with three (0.5%) in-hospital neurologic complications and one death for a 0.16% mortality rate. Fifty-eight percent of the patients were discharged in 1 day. Patients staying 1 day were 3 years younger. Female gender and prior cerebrovascular accident were factors extending LOS to 2 and 3 days. History of angina, heart failure, valve disease, and vein patch or no patch contributed to LOS of 3 or 4 days. Completion arteriography had an association with LOS of 2 days. The relative percentage of patients with complications increased with LOS. No significant relationship was found for symptoms, smoking, myocardial infarction, atrial fibrillation, cardiac revascularization, or surgeon. Insulin-treated diabetes mellitus, cardiac risk factors, cerebrovascular accident, and vein patch or no patch correlated with prolonged hospitalization. Factors were identified that may alter a clinical pathway designed for discharge 1 day after CEA. Focused management of patients with cardiac and cerebrovascular accident history or requiring vein patch and a better understanding of CEA in women may further increase the percentage of patients discharged 1 day after CEA.     

Factors affecting length of stay after isolated femoral shaft fractures

BACKGROUND: Controlling escalating health care costs is important for hospitals and has far reaching implications for society. Hospital length of stay (LOS) is one of the most reliable predictors of cost after trauma. Our purpose was to establish LOS after isolated femur fractures treated by intramedullary (IM) nail. METHODS: The trauma registry was queried to identify patients. Patients were excluded if they required assistive ambulatory devices before injury, had chronic/terminal illness or compromised brain function. There were 102 patients with an average age of 27 years. Statistical analysis was completed. RESULTS: The average LOS was 3.9 days. In all, 27 patients stayed longer than 4 days. Reasons included social (7), medical (10), and hospital delays (10). The average time from arrival to surgery was 17 hours. The average time from surgery to physical therapy was 1.3 days. Patients who had surgery more than 24 hours after arrival stayed longer. Patients requiring placement stayed 2.4 days longer until placement was found. CONCLUSIONS: Factors the hospital can control to reduce LOS include time to surgery, time for physical therapy evaluation, and radiology delays (for spine clearance radiographs). Physical therapy availability within 24 hours of surgery is important and should include weekends and holidays. Early evaluation of social factors including homelessness or obstacles to independent living may reduce time to find placement. LOS reduction after femur fractures will decrease the cost of trauma to the hospital. In addition, LOS reduction will possibly increase bed availability and minimize the time spent on diversion yielding greater revenues and increasing patient satisfaction.     

Risk factors for prolonged stay after ambulatory surgery: economic considerations

The risk factors that prolong length of stay of ambulatory patients can be classified as preoperative, intraoperative, and postoperative. Preoperative factors include the type of surgery, ear, nose and throat and strabismus surgery, old age and pre-existing congestive heart failure. Intraoperative factors include increasing length of surgery, and general anesthesia, while postoperative factors include postoperative nausea and vomiting, excessive pain and adverse cardiovascular events. The factors that anesthesiologists can address to reduce length of stay are postoperative nausea and vomiting and excessive pain. Multimodal management of postoperative nausea and vomiting and pain can minimize adverse events and thereby reduce length of stay in the postanesthetic care unit, but will not necessarily lead to a reduction in staffing levels. As personnel costs contribute the majority of postanesthetic care unit costs, more than 95%, direct financial savings may not be possible from eliminating adverse events alone. Optimizing the use of the postanesthetic care unit and reducing total hours in the unit with higher operating room turnover may lead to indirect financial benefits.     

Factors associated with prolonged stay after laparoscopic cholecystectomy in elderly patients

Background Laparoscopic cholecystectomy in elderly patients has been linked to higher complication rates and longer lengths of stay. The purpose of this study was to identify risk factors associated with prolonged postoperative hospitalization in elderly patients undergoing laparoscopic cholecystectomy. Methods The records of 287 patients aged 65 years or older, who underwent successful laparoscopic cholecystectomy between January 2001 and July 2006, were retrospectively reviewed. Clinical data was abstracted from the chart and compared between patients with a shorter or longer postoperative stay. Results The median postoperative hospital stay was three days (interquartile range 3–5). Forty-eight patients had complications, with an overall morbidity of 16% and mortality of 0.7%. The only independent predictor of prolonged postoperative stay was the occurrence of any major complication [odds ratio, 3.144; 95% confidence interval (CI), 1.882–5.251]. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and underlying chronic obstructive pulmonary disease were independently associated with major complications. Conclusions A major complication is the most important cause of prolonged hospital stay after laparoscopic cholecystectomy in the elderly. No specific comorbidity has direct impact on the duration of hospitalization, but pulmonary disease is associated with increased risk of major complications.