Hi, this is Alexandra Santos, a last year medical student from University of São Paulo, Brazil. I'm going to present safety and cost analysis of early hospital discharge after brain tumor surgery, a pilot study. No conflicts of interest to disclose. Until early 1990s, there was little evidence about perioperative care. It was Engelman, in 1994, who started the concept of fast-track surgery in order to optimize postoperative recovery, reduce hospital stay and potential complications. Later, in 2005, ERAS, Enhanced Recovery After Surgery, represented a paradigm shift in protocols of care in DTI surgery. However, many neurosurgeons do not follow this concept on their practice. Nowadays, many neurosurgical centers still have a median of 4 days after craniotomy of postoperative care, even if no complications. But this is going to change, since there was an increase of publications in neurosurgery. Last year, a randomized clinical trial evaluating the implementation of the ERAS protocol concluded that there was a decrease of hospital length of stay, 4 days in the ERAS protocol, compared to 7 days in the control group, and also a decrease of the time to first oral liquid and solid food intake. Following the ERAS protocol, our institution, the Cancer Institute of São Paulo, has adopted a Daily Algorithm for Hospital Discharge, DAHD, and we designed a retrospective cohort study to evaluate whether there was a difference in length of stay, rate of complications, and hospital costs, after the introduction of the Daily Algorithm for Hospital Discharge. Patients who fulfilled all criteria were discharged from postoperative day 1. The patient was only kept inpatient if he objectively presented a real need for hospital care. The algorithm was applied every morning during our routine round. If the patient did not meet a single criterion, he was kept inpatient and re-evaluated on the next day. Therefore, the patient was only kept inpatient if he presented a real need for hospital care. Postoperative blood tests and head CT scan were performed within 24 hours and repeated as needed. So, on this figure, we can see all the criteria needed to be discharged. First of all, no risk of aspiration, pain well controlled, no IV medications, stable neurological exam, head CT with no complications, and also a patient willing to be discharged. We compared two groups, the pre-implementation group between January and August of 2017 and the post-implementation group between September and December of 2017, and the primary outcome was length of stay. We also compared demographic and procedure-related variables, clinical outcomes, and healthcare costs within 30 days. This study was approved by the Ethics Committee of our institution. Analysis was adjusted for the preoperative KPS. The pre-implementation group included 32 patients, while the post-implementation group included 29 patients. Demographic characteristics were similar between groups. After the algorithm, there was a decrease in the length of stay, 5 days before the protocol against 3 days after the protocol. Also, the proportion of patients who were discharged within 2 days after surgery was higher, 3% before the protocol versus 44% after the protocol. Complications, readmissions, and return to hospital in 30 days were comparable between groups. On this figure, we can see the significant decrease of hospital length of stay in days after the algorithm, from 5 days here in the group pre-implementation to 3 days in the group post-implementation. Sepsis was the most common major complication, and seizures the most common minor complication for both groups. 30-day return to the emergency department rate was 21% in the group pre-implementation and 29% post-implementation. However, the post-implementation group had less readmissions, 9%, comparing to 18% before the protocol. Mortality also did not differ between groups. There was a significant reduction in the median costs of hospitalization in the ADHD group, mainly due to a reduction in ward costs. Before the protocol, costs were around $1,600 and after that $900. The two groups were comparable concerning demographic and clinical variables, what gives reliability to our results. The reduction of length of stay and consequently nursing costs was determinant for healthcare costs decrease. We observed a high hospital readmission rate, what is probably associated with the performance status of our patients before surgery, since 30% of them had a preoperative KPS minor than 70. Complications, readmissions and mortality rate were similar between the two groups, what shows that early discharge was safe and feasible. Length of stay in the ICU did not change, because the algorithm could only be applied after the patient has been discharged from the ICU. That's why we need protocols to identify the patients who really need prolonged ICU stay, in order to reduce the number of unnecessarily assisted ICU patients and also decrease the total hospital length of stay. Finally, we had higher incidence of complications when compared to other similar case series, mainly because most of these previous studies selected patients with safer profiles and excluded those with worsened performance status, large tumors or posterior fossil lesions. Our case list was composed most by malignant tumors, which are more prone to complications. So our main conclusion, the implementation of a protocol for early hospital discharge of patients submitted to brain tumor surgery was safe and led to a significant reduction in hospital length of stay and hospitalization costs. Thank you very much. Thank you.

Alexandra Santos

medical student

University of São Paulo

early hospital discharge

brain tumor surgery