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Original article
Successful implementation of an appendectomy process improvement protocol
  1. Matthew Bradley1,
  2. Angela Kindvall1,
  3. Judy Logan1,
  4. Jeffrey Bailey1,
  5. Eric Elster1,
  6. Carlos Rodriguez2
  1. 1Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  2. 2Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
  1. Correspondence to Dr Matthew Bradley, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; mjbrad7{at}yahoo.com

Abstract

Background A key component of a process improvement program is the institution of hospital-specific protocols to address certain disparities and streamline patient care. In that regard, we evaluated the implementation of an outpatient laparoscopic appendectomy (OLA) protocol at a tertiary military hospital. We hypothesized that OLA would reduce length of stay (LOS) without increasing complications.

Methods In August 2016, our institution implemented an OLA protocol—defined as discharge within 24 hours of surgery. Exclusion criteria included age <18 years old, grade 4 or 5 appendicitis, immunosuppression, current pregnancy, and no supervision during the first 24 hours postdischarge. To determine OLA’s effect on LOS, analysis of variance was used to perform a comparison between the years 2014 and 2017. Successful outpatient appendectomies were recorded preprotocol and postprotocol, as well as readmission complications.

Results In 2017, the first full year of protocol implementation, 44 of 59 (75%) patients met the inclusion criteria, and all but 2 (42 of 44, 95%) stayed for less than 24 hours. Of the two outliers, one developed acute on chronic kidney disease and one had a slow return of bowel function following grade 3 appendicitis. Complications were low across all years (one per year). In 2017, the readmission was for percutaneous drainage of an abscess. Overall, protocol implementation produced a significant decrease in LOS.

Discussion OLA protocol decreased LOS at a military hospital and should be expanded to other department of defense (DoD) facilities. Further research is needed to identify cost benefit to the military health system.

Level of evidence III.

  • emergency care
  • appendectomy
  • acute appendicitis
  • improve patient care

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/tsaco-2019-000303

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    Footnotes

    • Contributors All authors have made contributions to the study design, data acquisition, or interpretation. In addition, all authors contributed to drafting or revising the article, and to the final approval of the version submitted.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Disclaimer The authors are military service members (or employees of the US Government). The opinions or assertions contained herein are the private ones of the author/speaker and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences, or any other agency of the US Government. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government. This work was prepared as part of their official duties. Title 17, USC, §105 provides that "copyright protection under this title is not available for any work of the United States Government.” Title 17, USC, §101 defines a US Government work as a work prepared by military service member or employee of the US Government as part of that person’s official duties.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The study was approved as a process improvement initiative by the Walter Reed National Military Medical Center’s Institutional Review Board (IRB) in compliance with all applicable Federal regulations governing the protection of human subjects.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article.