title: Development of an outpatient protocol for lumbar discectomy: our institutional experience.
abstract: BACKGROUND
  Traditionally, lumbar discectomy has involved overnight hospital admission. Recent literature supports the shift to same-day lumbar discectomy because of improved outcomes and better patient satisfaction scores. A successful protocol for outpatient lumbar discectomies was proposed and implemented at a single institution. The aim of this study is to perform a quantitative and qualitative analysis of this institutional model.
  
  
  METHODS
  Retrospective clinical data were collected for patients who underwent a lumbar discectomy during the period 2008-2012. Admission and readmission rates, emergency department (ED) visit rates, surgical complications, and differences between neurosurgeons specializing in spinal procedures and neurosurgeons not specializing in spinal procedures were analyzed before and after implementation of the outpatient surgery protocol.
  
  
  RESULTS
  Of 1011 cases identified, 643 cases of lumbar discectomy were performed before the implementation of the protocol, and 368 cases were performed after implementation. The admission rate before the start date of the outpatient protocol was 96.4% versus 50.3% after implementation. After protocol implementation, the most common reasons for admission were uncontrolled pain (18.9%), late operative start times (14.1%), comorbidities (13%), and intraoperative operating room complications (11.9%). Intraoperative complications consisted almost exclusively of dural tears. The 30-day readmission rate after protocol initiation was 4.6% (n = 17 of 368) versus 2.3% (n = 15 of 643) before initiation (P = 0.046), and ED visit rate not requiring an admission was 2.2% (n = 8 of 368) versus 1.1% (n = 7 of 643) before initiation (P = 0.170).
  
  
  CONCLUSIONS
  Our data demonstrate that a collaborative protocol for outpatient discectomy can be implemented in a safe and effective manner despite a statistical increase in hospital readmissions. The percentage rates of readmissions and ED visits accounted for a very small percentage of the overall number of cases after protocol implementation. Improvements in perioperative pain management and ensuring that outpatient lumbar discectomies are scheduled early in the day may further decrease the number of admissions. Future studies should examine the societal and financial impact of same-day discectomy versus overnight hospital stays.
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Shih-Shan
authors.initials: SS
authors.lastname: Lang
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: H Isaac
authors.initials: HI
authors.lastname: Chen
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Koch
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Kurash
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Kathryn R
authors.initials: KR
authors.lastname: McGill-Armento
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Palella
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
authors.affiliation: Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address: Neil.Malhotra@uphs.upenn.edu.
authors.forename: Neil R
authors.initials: NR
authors.lastname: Malhotra
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000379:methods* / Q000458:organization & administration; D000556:Ambulatory Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D001416:Back Pain / Q000209:etiology; D016208:Databases, Factual; D017586:Diskectomy / Q000009:adverse effects / Q000379:methods*; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006801:Humans; D007297:Inpatients; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D007431:Intraoperative Complications / Q000209:etiology; D007796:Laminectomy / Q000009:adverse effects / Q000379:methods*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010045:Outpatients; D010343:Patient Admission; D010359:Patient Readmission; D012189:Retrospective Studies
keywords: Discectomy; Laminotomy; Lumbar; Outpatient; Protocol; Same-day