title: Evaluation of a process-of-care model for open intravesical ureteral reimplantation in children from a contemporary health care perspective.
abstract: BACKGROUND
  Surgical management of patients with vesicoureteral reflux consists of both open and minimally invasive approaches. Open approaches are associated with postoperative hospitalization and stays of 2 to 3 days, dependent on the type of procedure; alternately, when endoscopic correction is performed, it is a same-day procedure. Changes in health care policy emphasize reduction in cost while maintaining and improving quality of care. We sought to evaluate the impact of a "1-night cost-saving process-of-care" model for open surgical correction of vesicoureteral reflux in children on quality of care, which was defined as a return to the emergency room (ER)/office or readmission to the hospital within 2 days of discharge.
  
  
  METHODS
  An institutional review board-approved retrospective chart review of all open ureteral reimplantations for uncomplicated vesicoureteral reflux from January 2009 through January 2013 was performed. Children who underwent ureteral stent placement and those who did not have a caudal anesthetic were excluded from the study. Length of postoperative stay, ER records, hospitalizations, and office records were reviewed to assess for presentation to the ER/office or readmission to the hospital within 2 days of discharge.
  
  
  RESULTS
  During the 4-year study period, 92 children (23 males, 69 females) underwent open ureteral reimplantation-there were 83 (89.1%) discharges on the first postoperative day; 9 (9.8%) on the second postoperative day; and 1 (1.1%) on the third postoperative day. One patient presented to the ER within 2 days of discharge, and 4 patients presented to the ER/office or were readmitted > 2 days after discharge.
  
  
  CONCLUSIONS
  Use of a caudal anesthetic, earlier catheter removal, a knowledgeable nursing team, and parental education allowed us to decrease the length of stay to 1 night in 82 of 92 patients (89.1%). These procedural changes allowed for a decrease in hospital stay comparable with and potentially shorter than robotic-assisted laparoscopic approaches. Additionally, these changes did not seem to increase the risk of early (≤ 2 days of discharge) presentation to the ER/office or readmission.
authors.affiliation: Professor of Urology/Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI. Pamelaellsworth@aol.com.
authors.forename: Pamela
authors.initials: P
authors.lastname: Ellsworth
mesh_terms: D000763:Anesthesia, Caudal / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007902:Length of Stay / Q000191:economics*; D008297:Male; D017146:Models, Organizational; D010351:Patient Discharge / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D017064:Process Assessment, Health Care / Q000458:organization & administration*; D012092:Replantation / Q000191:economics* / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014718:Vesico-Ureteral Reflux / Q000601:surgery*