R. C. Banning1, N. R. Bruce1, W. C. Beck1, J. R. Taylor1, M. K. Kimbrough1, J. Jensen1, M. J. Sutherland1, R. D. Robertson1, K. W. Sexton1 1University Of Arkansas For Medical Sciences,Department Of Surgery,Little Rock, AR, USA
Introduction:
The prevalence of gallbladder disease in the United States has been estimated to be 20.5 million adults. Two major complications of biliary disease are biliary pancreatitis and acute cholangitis, both of which may lead to shock and death. It is therefore important that this condition is promptly diagnosed and that definitive treatment – i.e., surgery or endoscopy – is not delayed. Previous studies have shown that patients at intermediate risk for having choledocholithiasis who proceeded directly to surgery had a shorter median length of stay compared to those patients who received endoscopic therapy first. Therefore, in patients for whom there is a high clinical index of suspicion for choledocholithiasis, direct admission to a surgical service may further decrease their length of stay, reduce the number of imaging and interventional procedures needed, and therefore the cost of the hospital stay. If a patient is admitted to a primary medicine service, however, they may experience unnecessary delay before surgical intervention.
Methods:
A retrospective study was conducted at an academic medical center on all patients admitted with biliary disease from May 2014 to May 2017. Diagnoses were grouped into the following categories: cholecystitis, choledocholithiasis, symptomatic cholelithiasis, cholangitis, congenital abnormalities, biliary fistula, and unspecified biliary disease. As part of a hospital wide protocol, biliary disease patients were admitted to a primary surgical service as beginning 10/1/2015. Outcomes were compared to medical service admission prior to the institution of this protocol. Data for the study were obtained from the enterprise data warehouse and an intention to treat analysis was performed. Aside from the admission to a surgical service, no additional protocols or care pathway changes were implemented. The primary outcome measure was length of stay.
Results:
The data set consisted of 12,945 admissions on 4,317 unique patients. Average length of stay was significantly shorter in the primary surgical service admission group (1.9 days ± 4.6 days; n=4505) vs. the primary medical service admission group (2.4 days ± 6.0 days; n=8440), with p<0.0001. When evaluating based on diagnosis, the decrease in LOS was statistically significant for cholangitis (3.4 days ± 6.9 days; n=636 pre-protocol, n=378 post-protocol; p=0.0191), cholecystitis (1.8 days ± 4.5 days; n=4380 pre-protocol, n=2141 post-protocol; p=0.0015), and symptomatic cholelithiasis (3.5 days ± 8.7 days; n=1206 pre-protocol, n=251 post-protocol; p<0.0001).
Conclusion:
This single-institution study suggests that admission to a primary surgical service may improve length of stay for patients admitted with biliary disease.