No Place Like Home: Surgical Home Recovery


Michele Knox, MD; Wendy Rabinov, MD; Michael Nwynn, MD;
Ashima Garg, MD, PhD; James Chang, MD;
Claire Spanbock, MBA, RN, CNOR; Edgar Servais;
Bijal Shah, MHSA; Tamar Fendel, MPH; Annie Davis, MPH;
Joeffrey Hatton, MBA

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Northern California

Background: Surgical home recovery builds on total joint home recovery and enhanced recovery after surgery, both of which focus on decreasing opioid use and improving pain control resulting in decreased length of stay. Similar techniques were used to improve same-day discharge rates to: Improve patient experience by enabling recovery at home with familiar food, environment, surroundings, and loved ones; free up hospital beds; and reduce exposure to hospital associated harm (eg, infection).
Methods: We identified lower acuity procedures with variation in current discharge practice. Specific criteria were applied to exclude patients with medical necessity for hospital admission including patients with a hospital stay of 2 or more nights. We identified surgeons with high rates of home recovery and identified best practices supporting home recovery. These were shared with all relevant surgeons through various forums. We developed an extensive performance reporting tool including: Statistical control charts trending 2-year performance for home recovery by Region, facility, procedure type, and surgeon, plus return to care data (return to Emergency Department, Operating Room, and/or hospital admission) with similar breakdowns.
Results: Procedures included: Anterior cervical discectomy and fusion Level 1 and 2, ankle fractures, 1-level laminectomy and discectomy, laparoscopic appendectomy, mandible osteotomy, mastectomy, parathyroidectomy, prostatectomy, thyroidectomy, tonsillectomy, shoulder arthroplasty, and vaginal hysterectomy. Between October 2017 and October 2018, home recovery for all procedures increased from 68% to 84%, statistically significant deviation from the mean for the past 8 consecutive months. This resulted in 2300+ bed days saved, representing annualized cost savings of approaching $7 million. During this same time frame, procedures with the highest increase in home recovery were: Prostatectomy or transurethral resection of the prostate (47% to 92%), mastectomy (37% to 79%), shoulder arthroplasty (38% to 74%), and laparoscopic appendectomy (66% to 83%). The most improved medical centers were San Rafael (68% to 96%), San Jose (59% to 85%), and Roseville (58% to 82%).
Discussion: Surgical home recovery can be accomplished without compromising quality, is preferred by most patients and families while hospital beds are freed up for others. We achieved statistically significant higher rates of home recovery within a few months. Success is attributable to: 1) self-nominated surgeon champions; 2) dedicated time for surgeons to discuss best practices, surgical techniques, and review data; 3) revealing reports identifying unknown variation in physician practice and highlighting opportunities by facility and procedure; 4) additional tools to share best practices: Video and written guidelines. These practices could quickly be adopted by other Kaiser Permanente Regions.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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