(Poster 88) A Novel Scorecard to Select Vaginal Hysterectomy Patients for Same-day Discharge

Objectives: Same day discharge (SDD) after vaginal hysterectomy with pelvic reconstruction surgery (PRS) has similar short-term complication and readmission rates compared to overnight admission with generally high patient satisfaction in appropriately selected individuals. In this study we aimed to increase the rate of SDD after vaginal hysterectomy with PRS by implementing and validating a clinical decision-making scorecard to identify patients appropriate for SDD.

Methods: A scorecard was developed and expert reviewed in which points were assigned based on factors previously found to be associated with need for admission including age, travel, length of surgery, and social support. Patients undergoing vaginal hysterectomy with PRS under the care of a single urogynecologist operating out of two academic tertiary hospitals were approached for inclusion. Enrolled patients were scored preoperatively and assigned to SDD or overnight admission pathways. On the day of surgery, patients were scored by a second involved surgeon. Patients were contacted 3-10 days postoperatively to complete a satisfaction survey. The primary outcome was the proportion of patients assigned to SDD that were discharged on the day of surgery. Secondary outcomes included factors associated with unsuccessful SDD, patient satisfaction, unscheduled healthcare visits, scorecard interrater reliability, and congruence between scores and surgeon decision making. A planned interim analysis was completed after 50 patients and pain and anxiety were identified as contributing to unplanned admissions. The short health anxiety inventory (HAI-18) and Pain Sensitivity Questionnaire (PSQ) were administered preoperatively to the second 50 patients. Providers were blinded to questionnaire scores.

Results: 70 patients were assigned to the SDD pathway and 10 (14%) had unplanned admissions (Figure 1). Reasons for admission included persistent anesthetic effects (3.4%), pain and/or anxiety (4.6%), oxygen saturation monitoring (2.3%), and transient hypotension (1.1%). Of patients discharged same day, 62% felt their stay was ‘too short’. Of those planned for admission 50% also felt their stay was ‘too short’. There were 9 emergency department visits and 3 readmissions in the postoperative period, which occurred between day 2 and 5 postoperatively (Table 2). The scorecard had 84% interrater reliability and 95% agreement between scores and surgeon decision making. HAI-18 and PSQ scores did not differ between those who underwent SDD and those with unplanned admissions. Mean HAI-18 scores (standard deviation) were 11.9(4.8) and 9.0(4.2) respectively (p=0.23). Mean PSQ scores were 52.5(27.9) and 62.3(30.9) respectively (p=0.41).

Conclusions: Selected patients could follow the SDD pathway with a high degree of success. Patient satisfaction was moderate across groups. HAI-18 and PSQ questionnaires could not predict unsuccessful discharges, but patient numbers were low. Future implementation in a larger cohort may better elucidate predictive factors.

Figure 1:
a one patient declined admission
b p = 0.50 Fisher’s exact test

Table 1:
a Fisher’s exact test
b Kruskal-Wallis test
c one missing value