Adoption of Same Day Discharge After Percutaneous Nephrolithotomy: Implications for Patient Safety and Resource Utilization
Joseph B. Black, MD, PhD, Symone Isaac-Wilkins, Boris Gershman, MD, Ruslan Korets, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Introduction: Percutaneous nephrolithotomy (PCNL) remains a recommended first-line therapy for individuals presenting with advanced stone burden and traditionally involves a 1-2 day postoperative hospitalization. There is emerging evidence that PCNL may be performed in an ambulatory setting, in the appropriately selected patient population. PCNL followed by same-day discharge presents an opportunity to improve health-care resource utilization and decrease costs associated with surgical treatment of nephrolithiasis. We aimed to assess the safety and quantify the financial implications associated with shifting PCNL to an ambulatory pathway.
Materials and Methods: A retrospective review of PCNL procedures was performed at a large academic medical center from January 2020 to June 2022. Patients were excluded from the ambulatory pathway and stratified into the inpatient pathway based upon complex medical comorbidities, planned multi-tract access, history of infection stones, need for overnight monitoring, intraoperative concern, inadequate social support, or if residing a long distance from the hospital. Preoperative clinical demographics and intraoperative parameters were compared between the two groups. To comparatively analyze cost differential between inpatient ambulatory PCNL, we used time-driven activity-based costing (TDABC), an accounting methodology used to calculate the cost of healthcare resources. A team of stakeholders created a detailed process maps and calculated personnel capacity cost rates. Once all personnel costs were determined, the costs were applied to the models for the inpatient and same-day discharge scenarios for the final cost comparison.
Results: We identified 101 PCNLs, of which 25 were ambulatory and 76 were inpatient. No statically significant differences were identified between age, gender, or comorbidity status. When compared to the ambulatory PCNL cohort, the inpatient PCNL group more frequently had standard (24Fr) access, a larger stone diameter, and a higher EBL. There were no statistically significant differences identified between the two cohorts in terms of readmission and 30-day complication rates or ED visits (Table 1). Inpatient PCNL was associated with estimated per-patient costs of $1977, while ambulatory PCNL was associated with per-patient costs of $1014. The inpatient stay portion contributed 43% of the overall personnel costs associated with inpatient PCNLs (Figure 1).
Conclusions: In appropriately selected patients, ambulatory PCNL represents a safe alternative to inpatient PCNL, without an increase in post-operative complications, ER utilization, or hospital readmission. Ambulatory PCNL pathway was associated with a cost reduction of $963 (49%) per patient, when compared to traditional inpatient PCNL. The main drivers of costs were nursing time during inpatient hospitalization and excess time spent in the post anesthesia care unit, suggesting potential targets for improved resource utilization and cost reduction efforts. 
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