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March
1997
What
Happens After Discharge? Return Hospital Visits After Ambulatory Surgery
Twersky R, Fishman D, and Homel P.
Anesth Analg 1997;84:319-24
[ see
abstract below ]
Dr. Twersky notes that less serious postoperative events after ambulatory
surgery do not receive much physician or analytic attention. This study
retrospectively examined a database of ambulatory patients to see whether
there were any trends for patients who returned to the hospital within
30 days after surgery. All visits were coded as to whether they were related
to the patient's ambulatory surgery or not.
ASU related ER visits and readmission to the hospital were examined. A
matched case control design was used (i.e. patients were chosen with similar
demographic (e.g. age, gender, etc.) and clinical variables (e.g. type
of surgery, date of surgery) who did not return to the hospital. Of 6243
ASU patients, there were 55 return visits to the ER related to ambulatory,
and 69 related readmissions to an inpatient unit or the ASU. Genitourinary
surgery had a higher overall return rate (5.8%) compared to other surgical
specialties (2-3%), p < .001, and GU surgery had a higher return rate
for complications as well. Hydrocelectonmy and varicocelectomy had higher
rates of infection than other operations. OF great interest (and a degree
of pride in our specialty) no readmissions occurred as result of medical
or anesthetic events.
Most common ER visits for all surgeries occurred as a result of bleeding,
and almost all patients were sent home, indicating a need for greater
patient education regarding what necessitates an ER return.
With this analysis, Twersky et al. can concentrate on better informing
their patients. If there were a national database with benchmarks for
return rates, the performance of the ASU physician and nursing staff could
be better assessed. If the problems were similar to that found in other
institutions, that would suggest medical/surgical issues rather than a
problem that was more unique to a particular ASU which would suggest a
particular ASU's personnel or policies needed more attention. Twersky'
review suggests that postoperative analysis should extend out to 7-10
days to identify most ASU related problems, and implies that the typical
1-2 day follow-up period may be insufficient for complete data analysis
of a particular ASU's operation.
As we concentrate on cost consciousness in the operating room, we must
not forget to look at the big picture. It is not enough to use a cheaper
drug or cut 2 minutes off of turnover time. It is to provide the most
efficient total perioperative experience. Besides the nature of the surgery
itself, anesthesiologists, clerical staff, administrators, surgeons, and
nursing personnel can all be factors that affect rate limiting steps in
patient throughput, and each can affect overall utilization in a variety
of ways.
By analyzing a large number of ambulatory experiences, Dr. Twersky has
elucidated some fascinating trends within her own institution, and the
approach she has used will serve as a template for us all to examine our
practices. We might spend an extra five minutes educating each patient
at risk for postoperative minor bleeding, add no identifiable costs to
the system, and eliminate many return ER visits. The push to managed care
has spurred this analysis. It is an exa mple of how the corporatization
of medicine can actually lead us to a more critical examination of what
we do, with results that are advantageous to our patients. It is the summation
of physician driven analyses like this and the resultant changes in physician
designed care maps that will ultimately result in the best and most efficient
patient care.
Return to the Current Literature Review
Front Page, or read the abstract:
ABSTRACT
The purpose of this study was to examine the frequency of return hospital
visits after ambulatory surgery discharge and to identify any predictor
variables for its occurrence.
A retrospective review of hospital records for all patients returning to
the same hospital within 30 days after ambulatory surgery was conducted.
Data on return hospital visits that resulted in rehospitalization (as an
inpatient or to the ambulatory surgery unit [ASU]) or treatment as an outpatient
in the emergency room were recorded. A total of 6243 patients underwent
ambulatory surgery over 12 consecutive months and 187 returned to the same
hospital of which 1.3% were for complications. Of all the returns, 54% returned
to the emergency room (ER) and 46% were rehospitalized as inpatients or
to ASU.
To identify factors associated with an increased likelihood of return, two
case controls for each return visit were obtained from medical records of
ambulatory surgical patients operated on during the same time period. Results
of the multivariate analysis on the matched case controls identified urology
as the only significant surgical service that predicted returns. (Odds ratio
27.87; confidence interval [CI] 3.78-74.86; P = 0.0002). A separate analysis
of the most common ASU procedures performed identified two surgical procedures
that predicted hospital return as compared with overall ambulatory surgical
population: patients undergoing varicocelectomy and hydrocelectomy procedures
were 8.3 times more likely to return (CI 2.090-23.75; P = 0.0042); patients
undergoing dilation and curettage were three times as likely to return (CI
1.78-5.55; P = 0.0002).
Bleeding was the most common reason for all hospital returns (41.5%), with
76.5% of these patients treated and discharged through the ER. The increased
likelihood of return visits after urology procedures warrants further evaluation.
As patients with bleeding were most likely to return to the ER and discharged,
more effective pre- and postprocedure patient education may further reduce
this occurrence. Better informing patients regarding the prognosis of bleeding,
and advising them of medical alternatives, could reduce inappropriate patient
returns to the ER.
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