Cholecystitis Fast Track Pathway Provides Safe, Value Based Care on Busy Acute Care Surgery Service

BACKGROUND: Fast track (FT) pathways have been adopted across a multitude of elective surgeries, with the culmination of their progress resulting in higher value-based care of the patient. However, these programs have been slow to be adopted into the acute care surgery (ACS) realm. We hypothesized that a FT pathway implemented in an ACS service would safely hasten patient progress to the operating room while decreasing patient length of stay. To minimize variation, we have selected a singular, common operation, the cholecystectomy, which can be compared across two hospitals with well-established ACS services, one with a FT pathway and one with a traditional pathway. METHODS: All patients at both hospitals that underwent an urgent or emergent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019 and October 31, 2019 were queried using CPT codes. Patients that required a conversion to open or partial cholecystectomy were excluded because they no longer qualified for the fast track pathway. Retrospective chart review was used to gather information relating to the patients' demographics, presentation, operative and hospital course, and outcomes. Time to OR and hospital length of stay were the primary outcomes. RESULTS: There was a total of 479 urgent or emergent laparoscopic cholecystectomies performed during the 6 months for acute cholecystitis. Four hundred and thirty (89.8%) were performed under the FT pathway and 49 (10.2%) were performed under the traditional pathway. The median [IQR] time to the OR following surgical consultation was not different between the two pathways: 14.1 hours [8.3-29.0 hours] for FT and 18.5 hours [11.9-25.9 hours] for traditional (p=0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours, [14.2-40.4] vs 38.5 hours, [28.3-56.3]; p<0.0001). Under the FT pathway, 33% of patients were admitted to the hospital and 75.6% were discharged from the PACU, as compared to 91.8% and 12.2% on the traditional pathway, respectively (both p<0.0001). 59.6% of FT patients received a phone call follow up, as opposed to the traditional pathway where all patients had clinic follow up (p<0.001). ED bounce back rate, readmission rates, and complication rates were similar between the FT and traditional pathways (p>0.2 for all). On multivariate analysis, having a fast track pathway was an independent predictor of discharge within 24 hours of surgical consultation (OR 7.6, 95% CI 2.9-20.2, p<0.0001). CONCLUSION: Use of a fast track program for patients with acute cholecystitis has a significant positive impact on hospital resource utilization without compromise of clinical outcomes. Shorter times in the hospital and fewer clinic appointments benefit the hospital, surgeon, and patient. Incorporation of a FT pathway into all areas of ACS should be investigated.