Definition and Prospective Assessment of Functional Recovery After Liver Transplantation: A New Objective Consensus‐Based Metric for Safe Discharge

Abstract

Standardized discharge criteria are critical to reduce premature discharge and avoid unnecessary hospital stays. No such criteria exist for patients undergoing liver transplantation (LT). To achieve a consensus‐based checklist of criteria for safe patient discharge after LT, this mixed‐method study included the following: a systematic literature review and expert discussion to draft a first checklist of post‐LT discharge criteria, defining patient recovery and indications for hospital discharge (functional recovery); an exploratory online electronic Delphi (e‐Delphi) study; a single‐center pilot study to test checklist feasibility; and a final e‐Delphi study with an extended interdisciplinary expert panel to validate the final checklist. The first round provided a 10‐point discharge checklist with 5 patient‐centered items derived from discharge criteria after liver surgery and 5 graft‐centered items derived from expert discussion. The restricted panel (9 experts) e‐Delphi provided 100% consensus after the second round, with slight modifications to the criteria. During the pilot study, 19 of 45 (42.2%) patients included fulfilled the complete checklist (100% of 10 items) after median (IQR) 16 (8‐21) days (functional recovery) and a length of stay of 20 (9‐24) days. The item with the lowest completion rate was minimum serum tacrolimus level in the target on 2 consecutive blood samples (n = 21; 47%), achieved at 13 (9‐15) days. The extended panel (66 experts) e‐Delphi provided 95%‐98% consensus after the third round, with slight modifications of the criteria. This study provided substantial consensus on discharge criteria after LT. We anticipate that these criteria will be useful in clinical practice to guide patient discharge and increase the comparability of results between future studies.

When is the optimal time to discharge patients after liver transplantation with respect to short‐term outcomes? A systematic review of the literature and expert panel recommendations

“…The safety and efficacy of an ERAS‐protocol might be measured by parameters such as early readmission rate, morbidity, mortality and cost‐effectiveness. In the reviewed literature, early readmission rate was comparable between the population with early versus regular/late discharge from hospital with a trend toward lower readmission in the ERAS group 8,14,16–19 . In daily clinical practice, a definition of functional recovery after LT would be a requirement for a standardized timely discharge protocol.…”

“…In daily clinical practice, a definition of functional recovery after LT would be a requirement for a standardized timely discharge protocol. As a first step, a checklist was established on confounders indicating the recipients´ postoperative course for a safe discharge policy 19 . The identification and treatment of susceptible risk factors that result in a longer hospital stay could further improve outcome.…”

New ERAS in liver transplantation – Past, present, and next steps

“…61 Published ERAS literature focuses on length of hospital stay, complications rate, and healthcare costs 62 ; however, the ERAS society highlights the need to focus on higher-level or crucially, patient reported outcomes, such as functional status, pain, fatigue, or quality of life, 61,62 metrics that are sadly lacking in work on liver transplantation. Recent efforts have been made to standardize the concept of "functional recovery" with a 10point checklist of patient and graft performance 63 but awaits validation.…”

Erratum

“…In the article by Brustia et al, ( 1 ) some of the affiliations were listed incorrectly, and some of the authors were linked to incorrect affiliations. The correct and complete list of author affiliations follows:…”