Risk factors causing unexpected conversion from ambulatory to inpatient admission among one- or two-level ACDF patients

Thursday, June 1, 2023

8:30 AM – 6:15 PM

Location: Salons 7-8

Presenting Author (Person doing the Podium Present(s)

ST

Soji Tani, MD, PhD

Spine Care Institute, Hospital for Special Surgery
New York, New York, United States

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Co-Author(s)

IO

Ichiro Okano, MD, PhD

Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
YD

Yusuke Dodo, MD, PhD

Spine Research Fellow
Department of Orthopaedic Surgery, Showa University School of Medicine
New York, New York, Japan
GC

Gaston O. Camino-Willhuber, caminowillhuberg@hss.edu

Hospital for Special Surgery
Brooklyn, New York, United States
TC

Thomas Caffard, MD

Spine Care Institute, Hospital for Special Surgery, United States
LS

Lukas Schönnagel, MD

Spine Care Institute, Hospital for Special Surgery, United States
EC

Erika A. Chiapparelli, MD

Spine Research Fellow
Spine Care Institute, Hospital for Special Surgery
NYC, New York, United States
VT

Vidushi Tripathi, BS

Medical Student
Weill Cornell Medicine
New York, New York, United States
AA

Artine Arzani, BS

Weill Cornell Medicine, United States
LO

Lisa Oezel, MD

Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, United States
JS

Jennifer Shue, MS

Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
WZ

William D. Zelenty, MD

Assistant Attending Surgeon
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
DL

Darren R. Lebl, MD, MBA

Spine Surgeon
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
FC

Frank P. Cammisa, Jr, MD

Chief Emeritus
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
FG

Federico P. Girardi, MD

Surgeon
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
AH

Alexander P. Hughes, MD

Surgeon
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
GS

Gbolabo Sokunbi, MD

Surgeon
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States
AS

Andrew A. Sama, MD

Co-Chief, Orthopaedic Spine Service
Spine Care Institute, Hospital for Special Surgery
New York, New York, United States

Submitter(s)

ST

Soji Tani, MD, PhD

Spine Care Institute, Hospital for Special Surgery
New York, New York, United States

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Disclosure(s):

Soji Tani, MD, PhD: No financial relationships to disclose

Introduction:
In an era of rising healthcare costs and pressure to improve patient satisfaction, surgeries are increasingly performed in an ambulatory setting. One example is anterior cervical discectomy and fusion (ACDF), which is one of the most common cervical spine surgeries. However, there are certain patients who are unexpectedly converted from outpatient to inpatient and little is known about the risk factors for conversion.
Aims/

Objectives:
The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory to inpatient in ACDF.

Methods:
This is a single-center, retrospective observational study. Patients who underwent one- or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were retrospectively selected. Patients were divided into two groups based on length of stay: 1) Ambulatory (Discharge within 24 hours) or Extended stay (fewer than 48 hours), and 2) Inpatient (greater than 48 hours). Baseline patient demographic data, surgical information, complications, and conversion reasons were compared between the two groups. Multivariable logistic analysis was conducted to consider independent risk factors for conversion to inpatient.

Results:
In total 662 patients underwent one- or two-level ACDF (median age, 52 years; 59.5% were male), with 494 (74.6%) patients discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic analysis demonstrated that female patients (OR, 2.89; 95% CI 1.80 to 4.63; p < 0.001), lower body mass index < 25 (OR, 2.56; 95% CI 1.55 to 4.24; p < 0.001), American Society of Anesthesiologists classification (ASA) ≥3 (OR, 2.55; 95% CI 1.21 to 5.39; p = 0.014), current smoker (OR, 0.16; 95% CI 0.05 to 0.50; p = 0.001), long operation time (OR, 1.01; 95% CI 1.01 to 1.01; p = 0.009), high estimated blood loss (OR, 1.01; 95% CI 1.00 to 1.02; p = 0.002), upper-level surgery (OR, 1.66; 95% CI 1.01 to 2.74; p = 0.045), 2-level fusion (OR, 2.05; 95% CI 1.28 to 3.28; p = 0.003), late operation start time (OR, 1.99; 95% CI 1.18 to 2.93; p = 0.008), and high post operative pain score (OR, 1.31; 95% CI 1.16 to 1.47; p < 0.001) were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) required reintubation or remained intubated for airway management. Airway management was significantly associated with higher ASA status, receiving oral anticoagulation therapy, medical history of hypertension, and obstructive sleep apnea syndrome of the patient.

Conclusions:
Our study demonstrates that several factors were considered risks for prolonged hospital stay after ACDF scheduled in the ambulatory setting. Although the number was small, certain patients may require reintubation or prolonged airway management. Surgeons should be aware that this potential life-threatening complication may occur after ambulatory ACDF. Focusing on modifiable surgical factors and pain management might reduce the conversion rate, benefiting patients and facilities.