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The Coordinated Team Approach to Shortened Hospital Stay Without Compromising Patient
Care
EARLY DISCHARGE AFTER VAGINAL HYSTERECTOMY
IRVIN J. REINER, M.D.
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OBJECTIVE:
To report on the feasibility and practicality of short stay (overnight) hospitalization of 567 patients undergoing vaginal hysterectomy and tabulate any complications referable to short stay hospitalization.
INTRODUCTION:A previous report (1) was designed to test the Hypothesis of early dismissal after overnight observation on a series of patients who underwent vaginal hysterectomy as a primary surgical procedure. This report deals with the expanded number of patients that were managed with this protocol.
MATERIALS AND METHODS:All of the patients in this series were private patients of the author from April 10, 1986 until June 1, The author was the only surgeon. The ages of the patients varied from 22 to 75 with an average of 42. In the original series patients with medical complications were excluded from the study (1). In the expanded study, no medical condition was deemed exclusionary providing the patient was a suitable surgical/anesthesia risk.
All of the patients in this study were counseled prior to surgery as to the type of surgery, the type of anesthetic to be used, the expected pain management, the expectation of their ability to ambulate and to tolerate a general diet. The patients were also advised of the possible conversion of the vaginal procedure to open laparotomy if intraoperative circumstances dictated.
The patients approached the post-operative period with intent of remaining in the hospital overnight and being dismissed in the morning if the parameters for dismissal were met.
There were some patients who met the criteria for dismissal on the evening of surgery, but their dismissal was delayed until the following morning.
Parameters for dismissal from the hospital included stable vital signs, free ambulatory activity, no evidence of unusual bleeding and no unusual pain that could not be controlled with simple oral analgesic agents.
Table 1 lists the types of surgical procedures performed. Table 2 lists the significant pathological diagnoses. The major indications for surgery was abnormal bleeding which was unresponsive to conservative management.
Laparoscopy was not used in any of these cases. The technique employed was basic vaginal surgical technique with refinements by the author.
Antibiotics were administered to all patients intravenously within thirty minutes prior to the surgical procedure. The antibiotic of choice was a long acting cephalosporin.
There was no attempt made in this study to compare one antibiotic to another. Table 5 lists the different antibiotics administered and the number of patients who received these drugs. There appeared to be no significant difference in the prevention of post-operative infection with any of the antibiotics administered. However, as the series was developed, selection of the antibiotics to be used was influenced by the hospital formulary as a cost-saving maneuver.
Post-operative pain medication used in these patients included nalbuphine (Nubain), oxycodone and acetaminophen (Tylox), propoxyphene and acetaminophen (Darvocet N), and acetaminophen and codeine (Tylenol #3). The addition of ketorolac (Toradol) to the protocol of pain management in the last 371 patients was an important adjunct to the overall patient pain control.
RESULTS:There were 567 patients who were entered into this series. There were 527 (92.9%) patients who were managed with this protocol. Table 1 lists the variety of surgical procedures that were performed on these patients. There appeared to be no direct correlation with the type of procedure as to the patients’ ability to conform to this protocol (1).
There were 40 (7.1%) patients who were not able to be dismissed the following morning after surgery. The reasons for their inability to be dismissed are tabulated in Table 3 as complications. Table 4 lists the patients that were readmitted at a later date for conditions that were believed to be related to the original surgery.
COMPLICATIONS:Table 3 summarizes those conditions that were listed as complications of the vaginal procedure that required either transfer of the patients’ status to inpatient status for further treatment. The most common problem was inability of the patients to void satisfactorily. This was a surprising finding in view of the fact that they did not have any anterior colporrhaphy done. Post operative pain was the second most common cause of change in status. In the first instance, bladder rest with catheter drainage for another 24 hours or less was sufficient to allow spontaneous voiding and dismissal. The use of extended parenteral and oral pain medications for an additional 12 to 24 hours, in those patients requiring further analgesics, was sufficient to allow them to be subsequently dismissed.
Of the three patients who required abdominal surgery at the time of their vaginal hysterectomy: one had a misdiagnosed Krukenberg tumor and two had significant intraabdominal bleeding to require abdominal exploration and therapy.
The three patients with bladder lacerations were transferred to inpatient status so their bladder treatment could be monitored more closely.
The patients who were classified with gastroenteritis may have had nausea and vomiting from the anesthetic and analgesic agents were it not for transient diarrhea.
Three patients were felt not to be candidates for dismissal on the morning after surgery because of significant intraoperative blood loss not requiring replacement. With an added day of expectant management and supervision they were all able to be dismissed.
The accidental laceration of the cecum was not discovered until the day following surgery. The patient’s definitive diagnosis was not established until 36 hours post-vaginal hysterectomy and bilateral salpingo-oopherectomy. She was managed by the general surgery service.
Readmission to the hospital at a later date because of conditions related to the original surgical procedure occurred in 4 patients (Table 4). The patient with delayed hemorrhage without a significant drop in her hematocrit and hemoglobin was managed expectantly without transfusion.
The patient with the infected seroma of the vaginal vault was readmitted five days after dismissal. She had immediate relief in signs and symptoms after the seroma was drained vaginally in the operating room under general anesthesia. The patient with the periappendaceal abscess was explored abdominally two days after dismissal from the hospital. It should be noted that these two patients who were readmitted with delayed pelvic infections both underwent vaginal appendectomy. Both responded well to management of their unanticipated complication.
The patient with the pelvic hematoma required transfusion to replace her circulating red cell mass, but no surgical intervention was needed.
DISCUSSION:Other authors (3,4,5,6) have pointed out the advantages of traditional vaginal hysterectomy as opposed to laparascopic assisted vaginal hysterectomy as well as the relatively under-utilized modality of this form of therapy. The success of the first series of patients using this protocol prompted the author to utilize and refine this protocol almost entirely in his practice.
While it is true that the actual surgical technique of the vaginal hysterectomy may be of paramount importance in this protocol, it is only one of four similarly important links in the chain. The other three are patient motivation, appropriate anesthesia and excellent post-operative nursing care.
It is beyond the scope of this paper to detail many of the minor points of the surgical technique used by the author. Suffice it to say that the development of the team concept in the operating room as well as the re-thinking of post-operative management procedures is paramount.
Patients are individually selected and counseled regarding this protocol. Patient motivation is evaluated at the time of pre-operative counseling. The patients are counseled as to the post-operative pain management and activity, not only by the author but also by the office and hospital staff.
It is beyond the province of the surgeon to administer the anesthetic to the patients. The professional interplay between the surgeon and the anesthesia department is important in the choice of agents during and after the surgical procedure. Consistency with the administration of anesthesia was achieved with collegial interaction.
The management of post-operative pain required the close cooperation of the surgeon and the nurses responsible for supervising pain management. Once the hospital staff understood the goals of appropriate use of analgesic agents in this series of patients, they were given the latitude to utilize their clinical judgement. It was incumbent on the surgeon to monitor and encourage the nursing staff to utilize bedside evaluation of each patient when achieving the appropriate level of post-operative pain relief.
At the time of dismissal from the hospital the patients were given both verbal and written instructions on home care. The day after dismissal from the hospital the office personnel contacted them by telephone. This was not only reassuring for the author, but also gave the patient an opportunity to review any other questions or problems that they may have encountered. In all cases, this approach was positive and the patients were encouraged to expand their level of activity.
No attempt was made to quantify hospital charges as was done by Mushinski (7). However, it is evident that this protocol would account for significant savings in overall medical care costs without compromising patient care.
CONCLUSION:
The results of this study indicate that vaginal hysterectomy by itself or combined with other vaginal procedures can be successfully done in a short stay (overnight) setting without any significant incidence of post-operative complications.
REFERENCES
- Reiner, IJ: Early Discharge after Vaginal Hysterectomy. Obstetrics & Gynecology 71:416-418, 1988.
- Reiner, IJ: Incidental Appendectomy at the Time of Vaginal Surgery. Texas Medicine 76:46-50, 1980.
- Summitt, RL, Stovall, TG, et al: Outpatient Hysterectomy: Determinants of Discharge and ehospitalization in 133 Patients. Obstetrics & Gynecology 171:1480-1487, 1994.
- Wilcox, LS, Koonin, LM, et al: Hysterectomy in the United States, 1988-1990. Obstetrics & Gynecology 83:549-555, 1994.
- Cosson, M, Querleu, D, et al: The Feasibility of Vaginal Hysterectomy. European Obstetrics & Gynecology 64:95-99, 1996.
- Han, GS: Assessing the Role of Laparoscopically Assisted Vaginal Hysterectomy in the Everyday Practice Of Gynecology. Journal of Reproductive Medicine 41:521-528, 1996.
- Mushinski, M: Hysterectomy Charges: Geographic Variations United States, 1994. Stat Bull Metropolitian Insurance Co. 77:2-12, 1996.
Irvin J. Reiner, M.D., F.A.C.O.G.
Spring Branch Women’s Clinic, P.A.
830 Long Point, Suite 302
Houston, Texas 77055
Office: 713-461-6902
Fax: 713-464-2633
E-Mail: JDFH37A@Prodigy.com
