Implementation of a “Same Night” Appendectomy (SNAppy) Discharge Protocol: A Quality Improvement Initiative

Abstract

Purpose

Appendectomy is curative for appendicitis and prolonged hospitalization is unnecessary for un-complicated disease. We implemented a protocol to expedite discharge of patients post-appendectomy.

Methods

Using multiple plan-do-study-act (PDSA) cycles, the protocol functions in three phases of care. Pre-operatively, expectations for discharge are established, antibiotics and acetaminophen are administered. Intra-operatively, a foley catheter is avoided and the maximum dose of local analgesic, routine skin prophylaxis, ondansetron and ketorolac are administered. Post-operatively, patients with stable vital signs, pain controlled, tolerating liquids and able to mobilize are discharged. The primary outcome measured was length of stay (LOS) post-procedure. Counterbalance measures were unexpected return to the emergency department (ED) and in-patient bed utilization. Impact of PDSA cycles was quantified using statistical process control charts and Mann Whitney U test. All statistical tests were 2-sided and P value ≤ 0.05 deemed to be statistically significant.

Results

A total of 332 patients were identified over a 2-year period, 147 pre-protocol implementation, 185 afterwards. The median age was 9 years old (IQR:6–11), procedure duration 40 min (IQR 29–53). The median post-op LOS pre-protocol was 11.2 h (IQR: 7.1–16.2) compared to 1.5 h (IQR: 1.1–4.2) after implementation (P < 0.00001). There were 10 returns to the ED pre-protocol (6.8 %) and 17 after implementation (9.2 %), (p = 0.65). Pre-protocol, no patients were discharged directly from the OR compared to 68 % after implementation. There was no difference in ED LOS (median 9:03 vs 9:14, p < 0.48).

Conclusion

Implementation of the SNAppy protocol significantly reduced the post-operative LOS and inpatient bed utilization without increasing ED returns.

Level of evidence

III.