Confirming the Safety of Outpatient Cleft Lip and Nasal Repair: To Admit or Not to Admit - That is the Cleft Lip Question
Artur Fahradyan, MD1, Izabela Galdyn, MD2, Beina Azadgoli, MS3, Michaela Tsuha, BS1, Mark M. Urata, MD, DDS1, Stacey H. Francis, MD4.
1Children's Hospital Los Angeles, Los Angeles, CA, USA, 2Loma Linda University Medical Center, Loma Linda, CA, USA, 3Keck School of Medicine of USC, Los Angeles, CA, USA, 4Sothern California Permanente Medical Group, Los Angeles, CA, USA.
PURPOSE:With no accepted protocol for inpatient versus ambulatory cleft lip surgery, this study looks to develop guidelines and review the safety of outpatient repair.
METHODS:Retrospective review of patients <2 years undergoing primary cleft lip and nasal repair from 2008-2015 at six centers was performed. Patients were divided into "predominantly ambulatory" (discharged vs. admitted for specific concerns) or "inpatient" (consistently admitted due to surgeon's preference). The impact of independent variables on admission, ED visits and readmission was analyzed.
Of 546 patients, 372(68.1%) were male, 416(76.2%) had unilateral clefts, 24(4.4%) had syndromes, and 129(23.6%) had comorbidities. Mean age at surgery was 4.6 months. 142(26%) patients were admitted. 49 admissions were due to surgeon's preference. After excluding this subset, our ambulatory surgery rate was 81%. There was no difference in ED visits (3% vs 2.2%, p-0.6) and readmissions (0% vs 1.45%, p-0.5) between groups. None of the ambulatory surgeries were readmitted within 36 hours (ambulatory surgery rate=100%). Gender, surgical time, prematurity and/or post-conceptual age <52 weeks, cardiac, respiratory, CNS, gastrointestinal, genitourinary and other congenital comorbidities had significant impact on admission rates in the predominantly ambulatory group (p<0.05). Respiratory comorbidities and syndromes were risk factors for readmission if patients presented to the ED (p<0.05).
CONCLUSION: Ambulatory cleft lip repair can be done safely in most patients with no difference in ED visits and readmission. Patients with significant comorbidities should be admitted for observation. Adopting an 81% discharge rate for cleft lip surgery in the US would save at least $8 million annually.
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