This study aimed to reduce hospital stay through improved pre-operative workup by analyzing data from patients undergoing orthopedic, laparoscopic, and spine surgeries. The results showed that completing pre-op tests and optimization according to guidelines was associated with shorter hospital stays. For example, patients who had pre-op workup done as outpatients rather than inpatients had shorter stays. The study recommended standardizing pre-op processes and investigations according to surgery type and patient risk to further reduce hospital costs and free up beds.

1. Project Title: Reduction In Hospital Stay Through Implementation Of Pre Operative Work Up.
Submitted By: Neha Bhilare
Wockhardt Hospital, Nashik
Purpose of the study: To reduce inpatient days of hospitalization through adequate
implementation of pre operative work up.
Objectives: 1) To understand the Pre operative process, identify gaps if any.
2) To prove whether pre op work up leads to reduced hospital stay.
3) To reduce inpatient days of hospitalization so as to reduce costs of inpatient care.
4) To schedule more surgical procedures by reducing hospital stay.
5) To use hospital beds for other non surgical patients
6) To anticipate length of stay for patients on the basis of pre operative make up.
7) To perform benchmarking in order to improve our length of stay (LOS) as per
market standards.
Materials & Methods:
Patients above the age of 12 years old having elective surgical procedures were eligible for
inclusion in the study. Patients have been sampled from 3 different surgical disciplines:
Orthopaedic (Total Knee Replacement), Laparoscopic surgeries (Lap Cholecystectomy, Lap
Appendectomy, Lap Inguinal Hernia repair) and Spine surgeries. The methodology used for data
collection is purely retrospective in nature, with cohort study in two surgeries.
A standardized pro forma sheet has been used to collect all the required information. The sheet
contained pre operative parameters like age, past history of patient, pre operative investigations,
co-morbidities, ASA** grades, Body Mass Index (BMI) date of admission, date of discharge etc.
Relevant data was obtained from the admission forms, patient’s medical records, the anesthetic
forms (PACs) and laboratory reports.
Data Analysis & Interpretation: Data collected was analyzed to find correlations between pre
operative factors and the total length of stay (LOS) to prove that adequate pre operative work up
leads to reduced length of stay. Some correlations like ASA grade Vs LOS, Age Vs LOS, BMI Vs
LOS, which were common to all the surgeries under study which showed direct correlations (i.e.
with increase in one variable the other also increases). Also a few findings were specific to a given
surgery. Following are the interpretations from the data analyzed given surgery wise.
Surgery 1: Total Knee replacement (TKR) (N= 51 patients): The pre operative times for TKR were
within acceptable limit and better than market standards. Also the data obtained was used to
assess the conformance of pre op investigations performed before TKR surgery at our hospital
with that of the NICE (National Institute Clinical Excellence) guidelines, UK. Results obtained
showed that if pre operative tests were performed as indicated by the guidelines, the length of stay
was shorter. Hence with deviation from the guidelines, the LOS increases. Also the LOS for TKR
patients showed deviations from the expected LOS due to the prevailing package stay at the
hospital. So taking in to consideration the surgeon’s opinion a cohort was performed to discharge
low risk patients well before the last day as per package (8 patients were discharged early with nil
rate of readmission.) This has further resulted in saving post operative hospital costs and indicated
the need to revise TKR package stay.
Surgery 2: Laparoscopic Surgery ( N = 124 patients): Here the data interpretations proved that
when pre operative work up is done on OPD basis ( Vs IPD) showed shorter pre op times and
ultimately shorter LOS. Also it was inferred that co-morbidity leads to an additional day of stay. A
healthy patient shows shorter length of stay compared to a patient with co-morbidity. Then the

2. rationale for the selective ordering of tests was observed which resulted in shorter pre op times,
saving costs and reducing false positive results leading to reduced length of stay.
Also patients with normal pre operative investigations showed shorter LOS compared to those of
patients with abnormal pre op make up. Hence proving that adequate pre operative evaluation
does lead to a reduced LOS. From the 3 Lap surgeries, Laparoscopic Cholecystectomy ( LC)
showed potential for high volumes and shorter LOS as compared to the other Lap surgeries, this
indicated that by conducting a Day care/ ambulatory LC procedure, we could attain high revenues
at low cost. Hence the study was further extrapolated “to assess the feasibility of conducting LC as
a day care procedure.” From the retrospective study it was inferred that 63% of population
indicated early discharge and 32 % of the population qualified for a day care LC procedure (LOS <
24 hrs).
Surgery 3: Spine surgeries (N=75): The various spine surgeries were studied to identify the
prolonged LOS. The main reasons for this were high pre operative times and high no of blood
transfusions. The distorted pre operative times ranged from (1day to 14 days). The various
reasons for the delay were further analyzed as delay in insurance approval, delay due to pre op
infection in patients, optimizing patient for surgery etc. Also the pre operative reasons for high
blood transfusions were: deranged Haemoglobin, prevailing bleeding disorders in patients and a
major contributor to this is the high intra operative blood loss.
Recommendations:
1) Patient education: Need for aggressive patient counselling through Pre Anaesthetics Clinics
(PAC), Information booklets, Audio-video tapes etc explaining the benefits of surgery, it’s
likely complications, counselling patients about pre operative requirements, explaining him
the plan of care and special emphasis on benefits of early discharge ( to encourage Day
care LC).
2) Revise Package Stay: Need to revise length of package stay (TKR ) since irrespective of
clinical indication patient stays for all package days, prolonging LOS.
3) Pre op Physiotherapy: Need for Pre op Physiotherapy sessions and weight reduction
programs for TKR patients, since majority patient population is obese showing delayed post
op ambulation and further prolonging LOS.
4) Pre operative Grid: Need for a standardized & customized Pre operative grid (guidelines)
for ordering of pre op investigations (Surgery wise and ASA grade wise), which would
enable judicious use of pre op investigations, save pre op time and hospital cost.
5) OT infrastructure: Need to further streamline OT booking process wrt availability of OT
infrastructure ( C arm, Lap units etc being shared)
6) Effective communication: The flow of information from IP billing ----Operation Theatre----
Levels-----PATIENT needs to be streamlined. There should be good intimation system right
from the arrival of the patient to taking him to the OT table.
7) Standardize Spine surgery stay: In each category of spine surgery there is high variation in
LOS within the group. A package can be prepared to standardize the stay and bring
uniformity.
8) Pre operative optimization: All the pre operative activities should be optimized before
admitting the patients like financial clearance (Insurance Approval), Clinically optimize the
patient before admitting the patient for surgery.
9) OPD Vs IPD: Perform most of the investigations on a OPD basis as it reduces LOS.
10)Using hypotensive anesthesia to decrease intra op blood loss.
11) Need for documentation and completeness of PACs, consent forms , Nursing assessment
charts, and Pain management charts etc .
*(ASA (American Society of Anesthesiologists) grades are a simple scale describing fitness to undergo an anesthesia. Patients are
graded as ASA grade 1- Normal healthy patient, ASA grade 2 - A patient with mild systemic disease, ASA grade 3 - A patient with
severe systemic disease, ASA grade 4- A patient with severe systemic disease that is a constant threat to life)