Same-day discharge for acute appendicectomy is safe: experience from a tertiary New Zealand hospital

The global lifetime incidence of appendicitis is approximately 8%, making it one of the most common reasons for acute surgical admission.¹ As a result, appendicectomy remains a frequent procedure in general surgery. The widespread use of laparoscopic surgery has shown a reduction in post-operative pain, shorter recovery and reduced length of stay post-operatively over open surgery. Despite these advantages, the majority remain in hospital for at least 1 night post-operatively² rather than same-day discharge (SDD). This is significant because the estimated cost of an overnight hospital stay in New Zealand exceeds NZ$1,000 and impacts acute and planned care workflows throughout the hospital, contributing to the overall burden on healthcare resources.

SDD following laparoscopic appendicectomy is an established practice, proven to be safe and effective in optimising bed availability and improving patient flow in multiple international studies.^2–5 Despite this, uptake of SDD acute appendicectomy locally remains selective, and there is resistance to change. Furthermore, no studies have specifically evaluated its safety within the New Zealand population.² To maximise the efficient use of our scarce healthcare resources, it is essential to assess whether SDD is safe in our population.

This study aims to compare complication and readmission rates between patients discharged on the day of their operation and those discharged on days 1 and 2 post-operatively.

Methods

All patients undergoing laparoscopic appendicectomy for uncomplicated appendicitis at Christchurch Hospital between June 2015 and March 2024 were retrospectively identified via the Solution Committed to Operative Procedure Excellence (SCOPE) surgical workflow programme. Ethical approval was obtained from the Health and Disability Ethics Committee (H24/0361).

The included patients were aged over 16 years with uncomplicated appendicitis, defined as the absence of suppuration, faecolith, perforation or gangrenous changes, and who had an inpatient stay of 0–2 days. Patients with suspected appendicitis and those having a diagnostic laparoscopic procedure in which the appendix was removed were included. Exclusion criteria included elective procedures, complicated appendicitis and inpatient stay 3 days or longer.

Patients were divided into two groups based on post-operative length of stay. The SDD group was discharged before midnight on the day of their operation, and the delayed discharge group was discharged on post-operative day 1 and 2. This was chosen to compare only those patients with an uncomplicated post-operative course.

The primary outcome of this review was complication rate, defined as Clavien-Dindo grade 3 or higher (requiring surgical or procedural intervention) within 30 days post-operatively. The secondary outcome was the 30-day readmission rate, defined as any admission to the Christchurch Hospital general surgery department within 30 days of the operation. The data warehouse was interrogated to capture patients readmitted to the hospital for any reason, under any specialty, within 30 days of appendicectomy.

SCOPE was used to obtain patient demographics, operative details and post-operative data, including complications. The first author validated data integrity by reviewing a random sample of 40 patient records (1.7% of the total patients) to confirm that complications and readmissions were correctly captured. A high capture of readmissions and complications was anticipated due to the public structure of acute care surgery in New Zealand.

Data collection and analysis were performed using Microsoft Excel and GraphPad Prism. Qualitative data were reported as n (%). All statistical comparisons were categorical and performed using the Chi-squared test; a p-value of 0.05 was set as statistical significance.

Results

A total of 2,258 patients underwent acute laparoscopic appendicectomy for uncomplicated appendicitis during the study period. Of these, 213 (9.4%) were discharged the same day and 2,045 (90.6%) after at least 1 night.

Baseline characteristics were similar between groups for ethnicity, American Society of Anesthesiologists (ASA) grade and Charlson Comorbidity Index (inclusive or exclusive of age). The delayed discharge group had a higher mean age (32.2 vs 29.9 years, p=0.008), a greater proportion of females (55.1% vs 37.6%, p<0.001) and longer operative time (54.2 vs 51.9 minutes, p=0.042). The mean time to discharge was 7.9 hours for the SDD group compared with 23.3 hours for the delayed discharge group. Morning operations (those taking place before mid-day) were significantly more common among patients discharged on day 0 than among those with delayed discharge (74.6% vs 26.3%, p<0.0001).

There was no significant difference in complication rates between the SDD and delayed discharge groups (0 [0%] vs 13 [0.6%], p=0.626). Similarly, 30-day readmission rates were comparable (15 [7%] vs 136 [6.7%], p=0.775).

View Table 1, Figure 1.

Discussion

The results of this study demonstrate that SDD following laparoscopic appendicectomy for uncomplicated appendicitis is both safe and effective, with no increased risk of post-operative complications or readmissions. These results align with existing international literature supporting SDD following laparoscopic surgery.^2,6,7 The intentions behind performing this study were also validated, as only 9% of patients in our hospital with uncomplicated appendicectomy were discharged the same day.

The findings also highlight that the time of operation plays a significant role; morning procedures are far more likely to result in SDD. This is consistent with the findings by Scott et al.³ and likely reflects better peri-operative logistics earlier in the day. Facilitating acute operative slots early in the day will be important in ensuring the success of a SDD protocol. Patients discharged home on the day of their procedure tended to be younger and had lower ASA scores, reflecting a lower-risk cohort (Figure 1). The lack of ASA 3 or 4 patients included in our study means the findings are unlikely to be generalisable to this group. Women were also less likely to have SDD after appendicectomy. This finding has not been previously reported and warrants further research.² Unfortunately, we did not collect data on which patients were offered SDD, or domiciliary data, which would have provided insight into discharge decision making. Future research should aim to identify and investigate factors predictive of safe SDD.

Limitations of this review include the retrospective design, which may introduce selection bias to those offered SDD. While not a clinically relevant difference, the SDD appendicectomy was approximately 2.5 minutes shorter, which may reflect a less complicated procedure or a more senior surgeon’s involvement. Secondly, the complication rates observed in this review are lower than the 3–5% rates reported in the literature for uncomplicated appendicitis.⁴ This discrepancy may exist because our review focussed solely on uncomplicated appendicitis in patients who were inpatients for fewer than 2 days, reflecting a population with straightforward recovery. Additionally, because complications within SCOPE require partially manual data entry, there is a risk of under-reporting. Lastly, as we could not capture grade 1–2 complications or presentations that did not require admission, we may have under-estimated minor complications. The 30-day readmission rate (6.7–7%) may reflect this or non-specific presentations unrelated to the appendicectomy. Despite this limitation, it is reassuring that there were no differences in readmissions between the groups.

The pathway to improving efficiency for our patients with UA will involve developing a hospital-wide SDD pathway. Internationally, the implementation of a SDD protocol after uncomplicated appendicitis has demonstrated an 88% success rate.⁵ Local factors must be considered, including the significant proportion of our population living in rural areas. Although we could not examine patient-reported outcomes, it is reassuring that the existing literature reports high satisfaction rates.⁸ Patient and caregiver education, both pre- and post-operatively, will be key towards driving change.⁵

In conclusion, these findings provide a strong foundation for a shift in clinical practice, enabling surgeons to recommend SDD for appropriate patients. There is real potential for resource saving, given the uptake of SDD appendicectomy was only 9%. By supporting SDD, surgical teams can help reduce the burden on inpatient hospital beds, decrease healthcare costs and improve overall patient flow without compromising safety.