Jul 25, 2014

Host: Now a shorter hospital stay and a faster recovery for children that need an appendectomy. We'll examine that next on The Scope.

Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. David Skarda, assistant professor in the department of surgery at the University of Utah. You know, it surprised me when I found out that appendectomy patients had to stay in the hospital for a certain number of days regardless of how they were actually doing. Can you talk about that a little bit and why you decided to examine that as a way to maybe help recovery and save some money?

Dr. Skarda: Traditionally, in pediatric surgery and, in particular, with younger patients who have appendicitis, we were very worried about the potential for complications and, in particular, infection inside the abdominal cavity. Because of that high degree of concern, we essentially created protocols for treating these patients after their appendectomy, which included relatively long durations of IV antibiotics lasting 7, 10, 14, sometimes 21 days and associated in-patient, in-hospital stay for that entire period. This did decrease the rate of infections, we think, but we just treated patients for a very long time with in-patient IV antibiotics.

Host: So at one point, that was a solution to a problem that somebody saw.

Dr. Skarda: That's correct.

Host: And then you kind of started reexamining it. What caused you to think, "Well, maybe we can actually shorten these stays?"

Dr. Skarda: We noticed here at Primary Children's that a fairly large percentage of these patients were ready to go home two or three days after their appendectomy. Because of the protocol that we had in place, they were required to stay in the hospital well beyond that point.

Host: Yes. So they were feeling fine, and everything looked good as far as you were concerned. But they had to stay.

Dr. Skarda: They had to stay because they were on IV antibiotics.

Host: Yeah. And because that's what the protocol was.

Dr. Skarda: And that was consistent, I think, with most children's hospitals across the United States.

Patient Experience Drives Protocol Testing

Host: All right. And then what made you think, "Maybe we can shorten this"? I mean, how do you go through that process of suggesting that this is a better way to do it, maybe?

Dr. Skarda: Well, we had talked about it as a group of surgeons for some time. Looking at that issue very closely, we realized that there was a very high likelihood that these patients who are ready to go home probably no longer needed antibiotics. And I think that the critical issue here was that not all patients with appendicitis necessarily respond the same way, and there are may be some that do not need antibiotics as long as others. If we can identify who they are, stop their antibiotics, and get them out of the hospital, they'll likely do better.

Host: Yeah. And actually, the data showed that.

Dr. Skarda: Yeah. Once we initiated our new protocol, which is clinical response based, meaning from the moment of the operation, we monitor patients every two hours at the bedside to see if they're drinking enough, eating enough, their pain is well controlled, and if they don't have a fever for 24 hours, they're ready to go home. Once they meet those criteria, then we send them home. We do check labs on their way out the door, basically, to see whether or not they need any oral antibiotics at home. Some of them do. Some of them don't. Then we follow them back in clinic in one week and make sure that they're doing well.

Host: And the hospital stay is shortened how much?

Dr. Skarda: This protocol decreased our hospital stay on an average of two days. So from 7 days to 5 days, and this decreased the cost of care by about $5,000 per patient with appendicitis and improved their outcome in terms of abscess rate from about nine percent to about five percent.

Host: Awesome. So it just went all the way around. Shorter hospital stay, less money, and better outcomes.

Dr. Skarda: That's correct.

Host: All right. And this was just all the post-operative procedure?

Dr. Skarda: That's right.

Standardizing Appendicitis Treatment

Host: But there's more to this story? You actually said, "Can we maybe do more?"

Dr. Skarda: Yes. Exactly. So although we accomplished a lot with the post-operative component of this, we realized that there are other areas where we could potentially improve. In most children's hospitals, there are many different surgeons performing appendectomies, and each of them perform their appendectomy in a slightly different way depending upon where they were trained, who trained them, and what seems comfortable for them.

Oftentimes, though, the instruments used to perform the appendectomy are relatively expensive. Given this variable nature of a lot of ways to make a taco or do an appendectomy, what we figured out is that there's probably a good way that we can perform appendectomies. We can essentially standardize the procedure so that everyone's doing it the same way. I then spent a lot of time and identified a specific set of devices and a specific way to do the appendectomy that was cost-effective and efficient. I then got all of my partners to agree to do that at Primary Children's.

Host: Was that hard to do?

Dr. Skarda: You know, it actually wasn't. I think once they saw the data, they saw the variability, they saw the cost involved, and they saw what was possible in terms of doing it all the same way, they actually agreed to it fairly quickly. Then once the procedure itself was standardized, we were able to decrease the cost per appendectomy at Primary Children's from about $800 or $900 in disposable devices that would never be used again to about $150 to $200 of disposable devices and, quite frankly, reusable devices. We've had this in place now for more than a year, and given our rate of appendectomies here at about 500 per year, that ends up being a cost savings of around $200,000 to $250,000 a year.

Host: Not an insignificant amount of money, especially in today's day and age when everybody's talking about healthcare costs and insurance premiums.

Dr. Skarda: Right. Well, it's really all about value, which incorporates the importance of having good outcomes. We monitor those as we made these changes, and, again, our outcomes have actually improved. We're having fewer abscesses, shorter duration of hospital stay, shorter operative times, and our physicians are happy. And more importantly, the parents and our patients are happy.

Blazing the Trail at U of U Health

Host: Yeah. That's exciting stuff. Is this kind of a common thing, that procedures are standardized and we don't necessarily look at the equipment used as closely as we should throughout medicine, or was it just kind of unique to this procedure?

Dr. Skarda: I suspect there's been some drive towards standardizing procedures in other countries. However, in the United States, to my knowledge, this is the first successful attempt to do that.

Host: Well, that's exciting. Are other hospitals finding out about this, asking you how you did it? Is this something you're passing along, paying it forward?

Dr. Skarda: Yeah. There's no question there. Other facilities are very interested in this. This data will be presented this fall at the AAP Conference in San Diego, and we anticipate that as this information and this idea is disseminated throughout the United States that there will be a significant degree of adoption. There's a great deal of interest, of course, in value, improving care, and decreasing cost. And this certainly fits into that category.

Host: Where are you looking at fixing next?

Dr. Skarda: We've also standardized cholecystectomy, or removal of gall bladders at Primary Children's. And we're considering moving onto other procedures.

Host: And final thoughts?

Dr. Skarda: I think there's an enormous opportunity in medicine and, in particular, at Primary Children's Hospital to standardize and improve care and improve value.

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