Most commonly collected and reported measures of hospital quality and safety end at the time of discharge. Unfortunately, those do not tell the entire story. Particularly as lengths of hospital inpatient stay have plummeted over the past 2 decades many post-surgical complications go unreported because surveillance/reporting systems have not traditionally followed the patient to the ambulatory setting.
In New York we have had a comprehensive reporting system for cardiac surgery since 1989. For many years, the primary metric receiving attention was the risk-adjusted mortality rate. But then Ed Hannan and colleagues (Hannan 2003) began to look at what happens to those patients after discharge following cardiac surgery. Using New York State's Cardiac Surgery Reporting System (CSRS) they found that over 15% of those surviving patients were readmitted within 30 days of discharge and that most (84,5%) of the readmissions were, in fact, for reasons related to the surgery. Almost 30% of those readmissions were for infectious complications. That led to efforts to increase the period of surveillance to at least 30 days after surgery. A subsequent study (Hannan 2011) showed little change in those readmission rates or reasons.
The widely quoted study on Medicare readmissions noted that for surgery discharges the majority of readmissions were for medical rather than surgical diagnoses (Jencks 2009). But that does not mean the reasons for readmission were not for complications of the surgery.
Now a new study (Kazaure 2012) has used a large database to identify post-discharge complications following a variety of general surgical procedures. Using data on over 500,000 patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) they determined rates of complications, reoperations, and mortality occurring within 30 days. They found that 16.7% of surgical patients had a complication and that 41.5% of those complications occurred after discharge. Most of the post-discharge complications (75%) occurred within the first 14 days after discharge. They concluded that complication rates vary by procedure, are commonly surgical site related, and are associated with mortality.
The most common post-discharge complications were superficial surgical site infections, organ space infections, severe sepsis, UTI, deep surgical site infection, wound dehiscence, DVT, pneumonia, septic shock and pulmonary embolism.
Patients who had experienced an in-hospital complication were at greater risk of having a post-discharge complication as well. Those who had post-discharge complications had a 3-fold increase in reoperations and mortality. Independent predictors of post-discharge complications were prolonged OR time, occurrence of an in-hospital complication, and an ASA score greater than 2.
There was considerable variation between type/site of surgery and complication rates and the distribution of inhospital vs. post-discharge complications. The highest proportion of post-discharge complications was seen with breast surgery, bariatric procedures, and ventral hernia repairs.
They note that the first 2 weeks after discharge are the most vulnerable so they recommend strategies such as ensuring a prompt physician visit post-discharge or using a nurse practitioner to coordinate care. Using a discharge checklist and coordinating care with home care providers are other recommended strategies. Perhaps using some of the strategies used in our other column this month “Joint Commission Collaborative on Colorectal SSI’s” might also reduce many of these complications.
Hannan EL, Racz MJ, Walford G, Ryan TJ, Isom OW, Bennett E, Jones RH. Predictors of readmission for complications of coronary artery bypass graft surgery. JAMA 2003; 290(6): 773-80.
Hannan EL, Zhong Y, Lahey SJ, et al. 30-day readmissions after coronary artery bypass graft surgery in New York State. JACC Cardiovasc Interv 2011; 4(5): 569-76.
Jencks SF, Williams MV, Coleman EA.. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. NEJM 2009; 360: 1418-1428
Kazaure HS, Roman SA, Sosa JA. Association of Postdischarge Complications with Reoperation and Mortality in General Surgery. Arch Surg. 2012; 147(11): 1000-1007
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