Clinical and economic consequences of early discharge of patients following supratentorial stereotactic brain biopsy

Object. The goal of this study was to determine the clinical and economic c onsequences of early discharge (< 8 hours) of patients following stereotact ic brain biopsy (SBB). Methods. The records of all patients who underwent percutaneous SBB at The Cleveland Clinic Foundation, a tertiary care teaching hospital, during 1994 and 1995 (Group A) were retrospectively reviewed to collect data on the na ture and timing of perioperative (< 48 hours) clinical and radiological com plications. Biopsies were performed using image-guided stereotaxy either wi th or without a frame. Based on the results, guidelines for early discharge of patients following SBB were implemented. Information on the nature and timing of perioperative complications was also collected prospectively in a ll patients who underwent percutaneous SBB from January 1996 through July 1 998 (Group B). Hospital financial records for patients who underwent SBB in 1997 and 1998 were also reviewed and assessed for net revenue stratified b y discharge status: early discharge (< 8 hours), extended outpatient observ ation (greater than or equal to 8 and < 24 hours), and inpatient hospitaliz ation (greater than or equal to 24 hours). In Group A, 130 biopsies were performed. There were five serious complicati ons (3.8%), of which four were transient, and there was one death (0.8%). T he death and any sustained deficit occurred in patients in whom a clot had been demonstrated on postoperative CT scans. All complications were detecte d within 6 hours after surgery. Intraoperative bleeding occurred in 12 pati ents (9.2%), but was associated with only 40% of cases in which hemorrhage appeared on postoperative CT scans. Guidelines for early discharge (< 8 hou rs) following SBB were developed and stipulated the absence of the followin g: 1) intraoperative hemorrhage; 2) new postoperative deficit; and 3) clot on a postoperative CT scan. In Group B, 139 biopsies were performed. There were three serious complicat ions (2.2%), one of which was sustained due to a clot that had been demonst rated on the postoperative CT scan. All complications were detected within 6 hours postsurgery. There were no deaths in this group. Intraoperative ble eding occurred in 11 patients (7.9%), requiring intraoperative craniotomy t o control bleeding in one case. Hospital financial records were available for 96 patients, of whom 22 were discharged from the hospital early, II were observed for an extended outpat ient period, and the remainder were retained for inpatient hospitalization. Average net hospital incomes on technical charges for patients in the inpa tient hospitalization, extended outpatient observation, and short-stay (ear ly discharge) groups were $1778, $1175, and $1219, respectively, in 1997, b ut declined to -$889, -$1339, and $671, respectively, in 1998. The ratios o f indirect costs to direct technical costs were 132.5%, 128.7%, and 103.7%, respectively. Conclusions. Early discharge of patients following SBB of supratentorial le sions is safe in the absence of excessive intraoperative bleeding, new post operative deficit, and clot on a postoperative CT scan. Extended outpatient observation (8-23 hours) is not clinically necessary and may be economical ly prohibitive in the setting of a teaching hospital.