An Enhanced Recovery Protocol that Facilitates Same-day Discharge for Simple Laparoscopic Appendectomies

Introduction: Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA. Methods: A multidisciplinary team developed this protocol to facilitate same-day discharge after observing high rates of overnight stay due to PONV among simple appendectomies performed in 2011-2012. The protocol was implemented in November 2014 and underwent a revision in June 2016. Following the implementation of the protocol, we monitored the patients undergoing an LA at Nationwide Children's Hospital between November 2014 and August 2017. Results: We identified 691 patients (255 female) who underwent a simple LA at Nationwide Children's Hospital between November 2014 and August 2017. The patient population had a median age of 11 years (interquartile range: 9, 14). Among these patients, 514 (74%) were discharged on the day of surgery, and 387 (56%) were protocol compliant. The rate of same-day discharge was higher for compliant cases (79%) than noncompliant cases (69%, P = 0.003). Multivariable statistical analysis associated compliance with an increased likelihood of same-day discharge (Odds ratio [OR] = 1.7, 95% CI: 1.2, 2.4, P = 0.002). Conclusions: Implementation of the LA protocol to reduce PONV demonstrated a significant increase in the rate of same-day discharge from the hospital among compliant patients. Also, the adoption of a protocol to select patients for early discharge after LA has shown results with a 45% reduction in the need for inhospital beds.