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Validity and Utility Testing of a Criteria-led Discharge Checklist to Determine Post-operative Recovery after Abdominal Surgery: an International Multicentre Prospective Cohort Trial

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Abstract

Background

Criteria-led discharge (CLD) has promising potential to reduce unnecessary hospital stay after abdominal surgery; however, the validity and utility of CLD is uncertain as studies are limited to small single-centre studies involving predominantly elective colorectal surgery.

Methods

This prospective international multicentre cohort study explored the relationship between a CLD checklist, post-operative recovery, and hospital length of stay using patient-level data from four clinical trials involving 1071 adults undergoing all types of emergency and elective abdominal surgery at five hospitals across Australia and New Zealand. Patients were assessed daily for 21 post-operative days using a standardised CLD checklist. Surgeons and hospital clinicians were masked to findings. Criterion, construct, and content validity of the checklist to accurately reflect discharge decisions by surgical teams, assess physiological recovery, and encompass parameters signalling physiological readiness to discharge were tested. Potential utility of CLD to minimise unnecessary hospital stay was assessed by comparing day of readiness to discharge to actual day of discharge.

Results

The CLD checklist had concordance with existing discharge planning practices and accurately measured a longer post-operative recovery in more complex clinical situations. The CLD checklist in its current format did not detect all legitimate medical and surgical reasons necessitating a continued stay in hospital. Day of readiness to discharge was 0.8 days (95% CI 0.7 to 0.9, p < 0.001) less than actual day of discharge.

Conclusion

A CLD checklist has excellent criterion and construct validity in measuring physiological recovery following all types of major elective and emergency abdominal surgery. Content validity could be improved. The use of CLD has the potential to reduce unnecessary hospital stay although the safety of discharging patients according to the criteria requires investigation prior to implementation.

Trial registration

Trials were prospectively registered at the Australian New Zealand Clinical Trials Registry (LIPPSMAck POP 12613000664741, ICEAGE 12615000318583, PLASTIC 12619001344189, NIPPER PLUS 12617000269336).

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Acknowledgements

Bronte Biggins-Tosch and Kate Sullivan contributed significantly to this study by collecting a large proportion of the data. Medical students at the University of Tasmania, Dr Janice Tang, Dr Michael Kwok, and Dr Haoyuan Lim, also contributed significantly to data collection. Dr Leanne Fung acted as a blinded adjudicator for chest imaging and post-operative pulmonary complications. Dr Elizabeth Skinner and Dr Laura Browning contributed to discussions and design of embedding assessment of criteria-led discharge within LIPPSMAck-POP. Mr Iain Robertson, statistician, confirmed the analysis of these data using the statistical analysis plan designed by the primary author.

Funding

This study was an investigator-initiated trial funded by competitive research grants from the Clifford Craig Foundation, Launceston, Australia; the University of Tasmania (virtual Tasmanian Academic Health Science Precinct), Tasmania, Australia; and the Awhina Contestable Research Grant from the Waitemata District Health Board and Three Harbours Health Foundation, Auckland, New Zealand. Support was provided from departmental sources at each participating study centre (Launceston General Hospital, North West Regional Hospital, North Shore Hospital, Princess Alexandra Hospital, and North East Health Wangaratta) and sponsorship by the Tasmanian Health Service—North to support the Chief Investigator for the period of the trials.

Author information

Authors and Affiliations

  1. Department of Physiotherapy, Launceston General Hospital, Clifford Craig Foundation, TAS, PO BOX 1963, Launceston, 7250, Australia

    Ianthe Boden & Jane Lockstone

  2. Melbourne School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia

    Ianthe Boden, Jane Lockstone, Claire Hackett & Linda Denehy

  3. Department of Surgery, Launceston General Hospital, Launceston, TAS, Australia

    Calvin Peng & Nishanthi Gurusinghe

  4. School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand

    Julie Reeve

  5. Physiotherapy Department, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand

    Julie Reeve & Lesley Anderson

  6. Physiotherapy Department, Princess Alexandra Hospital, Woolloongabba, Brisbane, QLD, Australia

    Claire Hackett

  7. Physiotherapy Department, North West Regional Hospital, Burnie, TAS, Australia

    Cat Hill

  8. Physiotherapy Department, Northeast Health Wangaratta, Wangaratta, VIC, Australia

    Brooke Winzer

  9. Allied Health Research, Peter McCallum Cancer Centre, Melbourne, VIC, Australia

    Linda Denehy

Authors
  1. Ianthe Boden
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  2. Calvin Peng
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  3. Jane Lockstone
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  4. Julie Reeve
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  5. Claire Hackett
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  6. Lesley Anderson
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  7. Cat Hill
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  8. Brooke Winzer
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  9. Nishanthi Gurusinghe
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  10. Linda Denehy
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Corresponding author

Correspondence to Ianthe Boden.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethics committee approval

Trials were approved by each hospital’s respective ethics committee. LIPPSMAck-POP: Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia (protocol reference: H0011911), and the Health and Disability Ethics Committee, New Zealand (protocol reference: 14/NTA/233). ICEAGE: Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia (H0013666), Queensland Metro South Human Research Ethics Committee (17/QPAH/786), Victorian Northeast Health Wangaratta Human Research Ethics Committee (185), and Monash University Human Research Ethics Committee (CF15/2550—2015001039). PLASTIC: Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia (H0013754). NIPPER PLUS: Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia (H0016207).

Informed consent

Informed consent was obtained from all individuals included in the LIPPSMAck-POP, ICEAGE, and NIPPER PLUS trials. Local ethics committees waived the requirement to gain consent for data collection during the conduct of PLASTIC.

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Boden, I., Peng, C., Lockstone, J. et al. Validity and Utility Testing of a Criteria-led Discharge Checklist to Determine Post-operative Recovery after Abdominal Surgery: an International Multicentre Prospective Cohort Trial. World J Surg 45, 719–729 (2021). https://doi.org/10.1007/s00268-020-05873-9

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  • DOI: https://doi.org/10.1007/s00268-020-05873-9

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