Same day discharge after cochlear implant surgery: a retrospective study of patient satisfaction and outcomes

Introduction

Cochlear implant (CI) surgery is the standard of care for the treatment of severe to profound sensorineural hearing loss (1,2). Unlike traditional hearing aids which amplify sound, a CI directly stimulates the auditory nerve and bypasses dysfunctional structures of the inner ear (3). CIs have transformed the quality of life for patients by improving speech perception and communication abilities (4,5). As a major surgical intervention, CI requires specialised perioperative care to minimise complications, optimize outcomes and patient satisfaction.

CI surgery traditionally required post-operative inpatient monitoring due to postoperative concerns. However, advances in surgical techniques, anaesthesia, and postoperative care now support same-day discharge. Many otologic procedures, including CIs, are performed as day cases in the Netherlands, USA, Canada and United Kingdom (6-9). Studies have shown that same-day CI surgery is safe and feasible, with no significant differences in outcomes or complications compared to inpatient care (8,10). Additional benefits include improved patient satisfaction, reduced healthcare costs, and lower strain on hospital resources, without compromising safety or quality of care (11,12).

The shift to same-day discharge has been especially relevant in the context of the coronavirus disease 2019 (COVID-19) pandemic, which significantly impacted elective surgeries worldwide. In some Australian centres, elective otolaryngology surgery admissions decreased by 40% from pre-pandemic levels, with frequent cancellations, extended waiting times, and recurrent suspensions (13,14). Limited hospital bed availability was a major contributor, highlighting the need for innovative solutions, such as same-day discharge pathways, to address surgical demand (15).

A same-day discharge pathway for CI surgery was introduced at Flinders Medical Centre (FMC), South Australia, in August 2022 to address the waiting list of elective procedures. A clinical care protocol was developed between the Otolaryngology, Head and Neck Surgery department of FMC and ‘My Home Hospital’ (MHH), an out-of-hospital service. MHH provides acute care at home to eligible patients through a comprehensive multidisciplinary service that is overseen by doctors and includes daily nursing visits, allied health input, medication administration, and personal care if required.

For CI patients at FMC, MHH enables early discharge with continued post-operative care at home. Patients are assessed preoperatively for medical stability and social support suitability. Upon discharge, they are admitted into the MHH program, where care coordinators monitor their recovery, manage pain and complications, and arrange daily home visits and telemonitoring. The service aimed to replicate the safety and comprehensiveness of hospital-based recovery in the patient’s home environment.

The aim of this study is to evaluate whether same-day discharge following elective CI surgery is as safe and effective as an overnight stay, with no increased postoperative complications or adverse outcomes. We also aim to determine patient satisfaction with same-day discharge and assess its potential to improve hospital resource utilisation.

Methods

The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-41/rc).

Ethics

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective audit was conducted as a quality assurance project (Project Number: 4691) and was granted ethics exemption by the Southern Adelaide Clinical Human Research Ethics Committee. In line with the National Safety and Quality Health Service Standards and the Southern Adelaide Local Health Network (SALHN) Four Fields of Enquiry-Continuous Improvement framework, quality assurance and service evaluations do not require formal ethics approval. All data were de-identified and handled in accordance with institutional privacy protocols. Individual consent for this retrospective analysis was waived.

Study design

We conducted a retrospective observational cohort study by reviewing medical records of all patients who underwent elective CI surgery between 8^th of August 2022, after the introduction of the MHH pathway, and 1^st of October 2023. Patients were stratified into two cohorts based on discharge pathway, same-day discharge via the MHH program or overnight hospital stay, and postoperative complications and readmission rates were compared between groups. Patient satisfaction was assessed only in the MHH cohort.

Study cohort

The patient cohort was identified retrospectively via the audiology department CI register. Forty-five patients were eligible for inclusion during the study period between 8^th of August 2022 and 1^st of October 2023.

Inclusion criteria

Adult patients who underwent CI surgery at FMC during the study period were eligible for inclusion. Patients were stratified into two groups: those discharged on the same day through the MHH pathway and those admitted for an overnight hospital stay (OS group). Group assignment was determined preoperatively by a consultant CI surgeon based on clinical and social eligibility criteria from the MHH pathway.

Patients considered suitable for same-day discharge in the MHH group were over 18 years of age and did not have high-risk comorbidities such as obstructive sleep apnoea (OSA), body mass index (BMI) greater than 35 kg/m², chronic pain disorders, or bleeding disorders. In addition, a safe home environment with a responsible adult available to provide care during the first 24 hours post-discharge was required. Patients who did not meet these criteria, or who required closer post-operative monitoring for clinical reasons, were admitted to the overnight stay group.

MHH pathway

The structure and workflow of the MHH pathway for CI surgery is outlined in the Clinical Guideline Aftercare of Cochlear Implant and the MHH SAPOM Cochlear Implant Process documents (Appendices 1,2). All patients planned for CI surgery attended a multidisciplinary pre-admission clinic approximately 2 weeks before surgery. For those identified as suitable for MHH, the elective surgery nurse completed the referral to the MHH service and provided the patient with written information about the program. On the day of surgery, standard day of surgery admission protocols were followed, and patient suitability was re-evaluated post-operatively. In the post-anaesthesia care unit, clinical stability was assessed using a traffic-light triage system. Green-category patients who were afebrile, hemodynamically stable, mobilising safely, tolerating oral intake, and managing pain with simple analgesia were considered appropriate for discharge. Amber-category patients, such as those with low-grade fever, mild haemodynamic variation, or complex social factors, were assessed on a case-by-case basis. Red-category patients, including those with sepsis, delirium, poorly controlled diabetes, or no available support at home, were excluded from MHH.

If discharge criteria were met, patients were formally discharged from the hospital and admitted to the MHH program. Nursing staff submitted the finalised MHH referral, medication plan, discharge summary, and operative report to the MHH team. Where a formal discharge summary was unavailable, verbal handover was provided to the supervising MHH medical officer. Remote monitoring equipment, including a touchscreen tablet, thermometer, pulse oximeter, and blood pressure cuff, was delivered to the patient’s home, and transport was arranged accordingly.

At home, the patient was under the supervision of a medical officer from the MHH program. A nurse visited the home to install the monitoring equipment and provide education. Daily in-person nursing reviews were conducted, with remote monitoring of vital signs four times daily during the first 24 hours. Mastoid wound dressings were reviewed and removed after 24 hours. Patients were assessed for dizziness or balance issues, with physiotherapy arranged when indicated. An outpatient modified Stenvers view X-ray was scheduled for postoperative day one to confirm the implant position, performed either at the hospital or through a private imaging provider, and was reviewed by the ENT surgical team.

Discharge from MHH was based on clinical stability, adequate wound healing, return to baseline function, and the absence of complications. Once recovery was confirmed by the supervising MHH medical officer, patients were scheduled for follow-up at the FMC Ear Nose and Throat (ENT) outpatient clinic and provided with clear post-discharge instructions, including escalation pathways for clinical concerns.

Data collection

Patient electronic medical records were reviewed for medical history, operative time, admission length, 2-week readmissions, and postoperative complications. Data was extracted into a spreadsheet. Patient satisfaction surveys were collected in-clinic or over the phone.

Variables

For each group (MHH and OS), the following patient-related variables were analysed: age, OSA, hypertension, chronic obstructive pulmonary disease (COPD), ischaemic heart disease (IHD), history of falls, asthma, chronic pain, diabetes mellitus and history of colonisation with multi-resistant organisms (MROs). Admission-related variables such as operative time, total length of admission, post-operative complications and readmissions to hospital within 2 weeks of discharge were also analysed.

Satisfaction survey

The MHH group completed a satisfaction survey at their post-operative clinic review, as part of an ongoing assurance assessment of this novel clinical pathway. Those who had not completed this survey during their first post-operative clinic visit were followed up with a phone call. Each participant provided verbal consent for their de-identified responses to be included in the audit of patient satisfaction. The survey consisted of questions using a Likert scale from one (very dissatisfied) to five (very satisfied) across seven domains, including discharge instructions, visit satisfaction, staff satisfaction, post-operative support and feeling safe after discharge (Table 1, Appendix 3). Total scores range from zero to thirty-five, a 100%, indicating a very satisfied patient. An overall score of 20% indicated that the patients were very dissatisfied, 40% dissatisfied, 60% neutral, 80% satisfied with the overall MHH experience.

Statistical analysis

Descriptive statistical analysis was used for the satisfaction survey results in the MHH group. Comparisons of comorbidities, admission time, readmission and complications between the two groups included descriptive statistics and significance testing. Mann-Whitney U test was used to analyse continuous variables (age, operative time, admission time) and Fisher’s exact test for comparing categorical variables (presence of comorbidities, complications, readmissions). For Mann-Whitney U tests, the Hodges-Lehmann estimator and its 95% confidence interval were reported as a measure of effect size. A P value of <0.05 was considered statistically significant. Analyses were completed using R Studio (R version 4.3.0).

Missing data

Patients with incomplete records for discharge details or follow-up information were excluded from the final analysis. Only complete patient satisfaction survey results were included in the analysis.

Results

During the study period, 45 CI surgeries were completed at FMC after the introduction of the MHH pathway. Four patients initially scheduled for the MHH pathway required overnight admission due to the following circumstances: responsible adult unavailable to provide transport or early post-operative support; misplaced MHH referral, hence MHH staff were not available; post-operative nausea and vomiting requiring additional treatment and dizziness affecting mobility. All four patients were excluded from further analysis. Additionally, discharge and follow-up data were missing from the records of two patients who were also excluded from further analysis. A total of 39 patients were included in the study. Twenty-five patients were discharged on the day of their surgery with the MHH pathway (MHH group, n=25) and 14 patients were admitted for an overnight stay (OS group, n=14), see Figure 1.

Figure 1 Flow diagram of patient selection and inclusion for CI surgery pathway study. CI, cochlear implant; FMC, Flinders Medical Centre; OS, overnight stay.

Patient satisfaction

Survey results were analysed for 23 out of 25 of the patients in the MHH group (a response rate of 92%). Satisfaction survey data revealed a mean satisfaction score of 30 out of 35 (85%) [standard deviation (SD) 5.86], indicating that patients were, on average, ‘satisfied’ with the MHH pathway, see Figure 2. Eight out of 23 surveyed patients reported notable symptoms during their first night at home, including difficulty mobilising due to imbalance, nausea and pain. None of the patients reporting these symptoms required medical attention or presentation to the hospital. Patients reported a high overall level of satisfaction with the MHH pathway. The survey domains (see Table 1 and Figure 2) with the highest rated level of patient satisfaction included experience with the treating surgical team (4.74±0.75) and feeling safe at home (4.39±1.16). The domains with the lowest satisfaction scores included experience with the MHH visiting staff (3.91±1.56), and medication support (4±1.35), with several patients citing no need for medication support and giving a score of 3 out of 5, contributing to a lower overall rating for this domain. The main concerns raised pertaining to patients’ experience with MHH staff were regarding visit times not being pre-scheduled and, in some cases, occurring late in the evening after a late-afternoon discharge from the hospital. One patient reported that they were not visited by MHH staff on the day of their discharge.

Figure 2 Mean patient satisfaction scores across survey domains following same-day discharge cochlear implant surgery. Score of 1 very dissatisfied, 2 dissatisfied, 3 neither, 4 satisfied, 5 very satisfied. Error bars represent standard deviation. FMC, Flinders Medical Centre; MHH, My Home Hospital.

Patient factors and comorbidities

There was no significant difference in age between the MHH group and the OS group (MHH group: 66.7±15.7 years, OS group: 64.2±17.7 years, P=0.69). Mean difference between the groups was 2.5 years (95% confidence interval: −9.2 to 14.2). Rates of OSA were significantly different between groups, with four patients in the OS group compared with none in the MHH group (P=0.01). Rates of colonisation with MROs were also significantly different between groups, with three in the OS group and none in the MHH group (P=0.04). Observed incidence of medical comorbidities, including asthma, hypertension, COPD, IHD, history of falls, chronic pain and diabetes mellitus, were recorded, with no statistically significant differences between groups (see Table 2).

Operative time and length of stay

There was no statistically significant difference in operative time between groups. The mean difference in operative time between groups was 4.6 minutes (95% confidence interval: −32.8 to 23.5, P=0.74). As expected, the length of stay in hospital was significantly shorter for the MHH group, with a mean of 7.2±1.0 vs. 28.3±7.3 hours for those in the OS group (P<0.01). Median total length of stay in the MHH group was 19.3 hours shorter than that in the OS group (95% confidence interval: 17.4–21.2; P<0.001).

Complications and readmission rate

The readmission rate between MHH and OS group was not statistically significant. One patient in the MHH group was readmitted with a minor wound infection, which was treated with antibiotics. One patient in the OS group was readmitted with a reactivation of varicella zoster in the trigeminal nerve (V3 distribution). There was one complication identified in the MHH group at one week post-operatively, a small tympanic membrane perforation, which was considered unrelated to participation in the MHH pathway.

Discussion

This is the first Australian study (to our knowledge) of same-day discharge CI surgery using a protocol-led MHH pathway. Satisfaction survey results from the MHH group demonstrated that patients were overall ‘satisfied’ with the same-day discharge pathway, with a mean satisfaction score of 85% of the maximum possible score (Table 1, Figure 2). While the absence of a comparable satisfaction score from the OS group limits interpretation, these findings suggest that the same-day discharge model is acceptable to patients. Our findings are in keeping with previously published studies that found that same-day discharge post CI is safe and well tolerated by patients (6,8,16). A randomised controlled trial involving 30 adult CI patients found no clinically relevant post-operative differences in quality of life, patient satisfaction, objective and subjective hearing outcomes and postoperative complications between same-day and inpatient overnight admissions (8). The UK experience of day-case CI surgery found day-case unilateral CI surgery to be safe. It was well tolerated with no readmissions (6). A systematic review examining admission rates following day-case major otologic surgery found that it was a safe and feasible alternative to inpatient surgery for both children and adults (16).

As patients in our cohort were pre-selected for suitability for the MHH same-day discharge pathway, baseline differences between groups were expected. Of the comorbidities that we examined, OSA and a history of MRO colonisation were significantly more common in the OS group. The difference in rates of OSA between groups can be explained by local day-surgery admission criteria, which exclude patients with OSA from day-case surgeries. Practice guidelines from the American Society of Anesthesiologists (ASA) recommend prolonged post-operative monitoring for OSA patients undergoing ambulatory surgery due to the increased risk of respiratory complications, including desaturation (17). However, Wu et al. found that 52.5% of OSA patients did not require hospital admission after ambulatory ENT surgery, regardless of their surgical indication or procedure type (18). The study also identified older age and higher ASA scores as independent predictors of post-operative admission, suggesting that risk stratification based on these factors may be more appropriate than blanket admission policies for all OSA patients (18).

The clinical significance of the difference in MRO colonisation between groups is unclear, as MRO precautions are not taken into consideration by MHH when accepting care of a patient, nor do they feature in our local day surgery admission criteria. In this study, rates of comorbidities, including COPD, IHD, diabetes, falls, and chronic pain, were very low across both groups, making it difficult to draw meaningful conclusions regarding their influence on the admission pathway. With larger cohorts, it may be possible to identify whether specific comorbidities beyond OSA predict the need for overnight admission. Notably, four patients initially scheduled for same-day discharge required conversion to overnight admission due to either clinical (postoperative nausea/vomiting, dizziness) or logistical factors (lack of a responsible adult, administrative error). These cases highlight both the value of a final suitability check and the flexibility of the pathway, ensuring safety through the option of inpatient admission when necessary.

Importantly, in all other parameters investigated, we found there was no significant difference between the two groups, including in rates of post-operative complication and readmission to hospital. This study’s findings demonstrate that most patients can be good candidates for day-case CI surgery, despite advanced age or the presence of multiple medical comorbidities.

A significant advantage of the MHH same-day discharge pathway was a reduction in hospital length of stay (LOS). The mean LOS for MHH patients was 432 minutes (approximately 7.2 hours), compared to 1,696 minutes (approximately 28.3 hours) in the OS group. The primary value of the MHH pathway lies in its ability to save time, as prolonged inpatient stays contribute to delays in elective procedures. By enabling surgery without the need to wait for overnight bed availability, the MHH cochlear program facilitates timely access to care while optimising patient flow. Through the implementation of structured MHH programmes, hospital bed utilization can be optimized while patient safety and satisfaction are maintained. Although individual patient costs for the MHH program were not available due to its state government bulk funding model, the cost of an overnight hospital bed is estimated at $1,250 per night. This suggests that, beyond clinical and patient-centred benefits, the MHH program may offer economic advantages by reducing inpatient bed usage.

This study has several limitations that should be considered when interpreting the findings. The primary limitations were the study’s non-randomized, retrospective design, which introduces selection bias. Patients were chosen for same-day discharge based on pre-established suitability criteria, meaning those in the MHH group may have fewer comorbidities or a lower perioperative risk compared to the overnight stay group. This inherent selection bias probably explains why the observed outcomes were due to the same-day discharge pathway. The relatively small sample size, particularly in the overnight-stay cohort and the low event counts for comorbidities, complications, and readmissions, reduce statistical power, meaning the study was not powered to detect modest differences in these infrequent outcomes; therefore, non-significant findings for these secondary endpoints should be interpreted with caution. Additionally, the patient satisfaction questionnaire was not validated, which may affect the reliability of the responses.

The study’s generalizability is limited by its single institution setting and regionally funded post-operative care service. Differences in hospital infrastructure, surgical protocols, and post-discharge monitoring services may affect the feasibility and outcomes of similar programs elsewhere. Moreover, while patient satisfaction was assessed, the post-operative quality of life or functional hearing outcomes were not analysed for this study. Other papers have described comparable results in both post-operative outcomes and quality of life when comparing inpatient and day-case surgeries in otolaryngology (10). Although the patients are under the care of a nurse and doctor provided by the MHH program, the patient’s adult support person is essential for the patient to be eligible for the MHH pathway. Patients from regional or rural areas in Australia are suitable for the MHH pathway if they stay in a hotel or motel-type accommodation in Adelaide, South Australia. The clinical support provided is a single visit at home by a nurse and remote supervision with review by a doctor or nurse as required for clinical deterioration or when contacted by the patient or their support person. Hence, a limitation of this pathway is patients who do not have a suitable adult support person to stay with them or patients with moderate to severe OSA.

Despite these limitations, the study provides valuable insights into the feasibility and patient satisfaction associated with same-day discharge after CI surgery. Future research should aim to address these challenges by incorporating larger, multi-centre cohorts, conducting prospective trials with quality-of-life measures, and assessing long-term patient outcomes to further refine and validate the findings.

Conclusions

This study supports the ongoing implementation of same-day discharge pathways, promoting efficient and patient-centred surgical care. At our institution, same-day discharge following CI surgery has been shown to be a safe and viable approach, with patients reporting it as satisfactory. Complications and readmission rates were comparable to overnight admissions, suggesting that with appropriate selection and remote post-operative monitoring, inpatient stays may be unnecessary for many CI recipients. Beyond clinical safety, the MHH program significantly reduces hospital length of stay, alleviating bed pressures and optimizing resource utilization. Its success underscores the potential of same-day discharge to improve surgical capacity while maintaining quality care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-41/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-41/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-41/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective audit was conducted as a quality assurance project (Project Number: 4691) and was granted ethics exemption by the Southern Adelaide Clinical Human Research Ethics Committee. In line with the National Safety and Quality Health Service Standards and the Southern Adelaide Local Health Network (SALHN) Four Fields of Enquiry-Continuous Improvement framework, quality assurance and service evaluations do not require formal ethics approval. All data were de-identified and handled in accordance with institutional privacy protocols. Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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