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The relationship between length of stay (LOS) and complications is a complex one. Complications may increase LOS and longer LOS exposes patients to a number of iatrogenic complications. For many years, we have tried to reduce LOS for most diagnoses and conditions. Especially in the past decade, with adoption of ERAS (Enhanced Recovery After Surgery) we’ve seen surgical LOS decrease even futher (see our February 11, 2020 Patient Safety Tip of the Week “ERAS Rocks!”). But we’ve always tempered our enthusiasm for getting patients out of the hospital with the concern that we may be discharging them too soon.
A new study alerts us that post-discharge complications following surgical procedures are, in fact, increasing. Li et al. (Li 2021) looked at ACS NSQIP data from 2014 to 2019 on over 500,000 patients who underwent surgical procedures of the colon and rectum; esophagus; hepatopancreatobiliary system involving the liver, pancreas, gallbladder and bile ducts; or gynecologic or urologic systems and identified complications that occurred from the date of discharge up to 30 days post-discharge. They found that the median LOS decreased from 3 days to 2 days over that time span. Though the overall rate of postoperative complications declined 1 percent over the five-year study, post-discharge complications increased 12% over the same period. As a proportion of all postoperative complications, post-discharge complications increased from 44.6% to 56.5%.
Complications that had higher rates over time included surgical site infections; other infections such as pneumonia, urinary tract infection, and sepsis; MI, cardiac arrest, stroke, and venous thromboembolism.
The authors stress that many of these complications are potentially preventable, with early recognition and management preventing progression to more serious conditions.
They also identified risk factors that were associated with a higher odds of post-discharge complications:
Recommendations to help avoid such complications include:
Given that overall complication rates decreased over the period of the study, the obvious question is whether the shorter LOS had a causal relation to the higher rate of post-discharge complications. The authors do note that surgeons are often unaware of these complications until patients present to the ED or hospital and that earlier recognition of some may have prevented progression to more serious complications (eg. recognition of a wound infection might have led to prevention of sepsis). We’ve also noted in the past, when looking at hospital readmissions, that many complications are “medical” rather than strictly “surgical”. That emphasizes the need for good communication not only between the surgeon and patient/family but also with the “medical” clinician(s) who will also be providing future care. You’d be surprised how often a patient’s primary care physician is not even aware their patient was hospitalized and had surgery.
Li RD, Merkow RP, Joung HSD, Chung JD, Bilimoria KY. Are We Chasing Shorter Length of Stay At the Expense of Post-Discharge Complications? Scientific Forum Presentation. American College of Surgeons Clinical Congress 2021
The COVID-19 pandemic has changed the way we practice medicine in many ways. And some positive things that will outlast this pandemic have also resulted. Many public health measures will be remembered when the next pandemic hits. And the strides made using mRNA technology will likely be utilized in approaching cancer and other diseases. Medical practices have also changed. The most obvious one is the emergence of telemedicine, which is likely to be here to stay even after the pandemic has ended (see our November 2020 What's New in the Patient Safety World column “Telemedicine Here to Stay But Use It Safely”). Another useful practice might be virtual medication history interviews and discharge education (see our April 7, 2020 Patient Safety Tip of the Week “Patient Safety Tidbits for the COVID-19 Pandemic”). And our January 2022 What's New in the Patient Safety World column “Some COVID-19 Practices May Outlast the Pandemic” noted 5 other hospital practices that are likely to outlive the pandemic (Gillespie 2021, Advisory Board 2021):
1. A centralized monitoring system
2. Daily meetings to pinpoint safety and quality concerns
3. Reducing the number of times workers enter patients' rooms
4. Guides for respiratory treatments to reduce the spread of disease
5. Safety precautions for visitors
Now, Peter Pronovost and colleagues (Pronovost 2022) have pointed out yet another unexpected patient safety benefit - remote patient monitoring. The authors make a good case that patient risk, rather than physical location, should dictate the degree of monitoring. They begin by noting that many patients with COVID-19 who deteriorated or died at home could have benefited from continuous pulse oximetry. Use of currently available technologies can be used to monitor patients at home and help avoid hospitalizations. And they note that some payment reforms already made by CMS have made at-home monitoring possible for acute as well as chronic conditions feasible.
They cite a cost-utility analysis of remote pulse-oximetry monitoring of patients with COVID-2019 (Padula 2021) which projected that remote monitoring could potentially be associated with 87% fewer hospitalizations, 77% fewer deaths, reduced per-patient costs of $11,472 over standard care, and gains of 0.013 quality-adjusted life-years.
Pronovost et al. state “Pulse oximeters used in hospitals can now be deployed at home with patient data relayed to smartphones, secure cloud servers, and web-based dashboards where physicians and hospitals can monitor the patient’s status in near real time.” They acknowledge that a separate team likely would need to be created to focus on remote monitoring. They go on to describe the barriers which must be overcome before health systems take greater advantage of this opportunity.
They envision a scenario where monitoring data would be sent by the patient or via a technology platform that automatically transfers data. Parameters for home monitoring could include blood pressure, heart rate, electrocardiogram, pulse oximeter, temperature, and others. The care team could include a nurse with physician oversight and data could be reviewed either in real time or intermittently, based on the patient’s risk for deterioration.
It's not just COVID-19 patients that could benefit from home monitoring. Reducing the need for acute care hospitalization is a goal for many other conditions. Having in place the technology, data management systems, and clinical teams envisioned by Pronovost and colleagues should be in the plans for every healthcare system. The time is right.
See also our other columns related to COVID-19:
Gillespie L. Hospital safety practices that will outlive the pandemic. Modern Healthcare 2021; December 14, 2021
Advisory Board. Covid-19 led to new hospital safety measures. These 5 will outlast the pandemic. Advisory Board 2021; December 15, 2021
Pronovost PJ, Cole MD, Hughes RM. Remote Patient Monitoring During COVID-19: An Unexpected Patient Safety Benefit. JAMA 2022; Published online February 25, 2022
Padula WV, Miano MA, Kelley MA, et al. A cost-utility analysis of remote pulse-oximetry monitoring of patients with COVID-2019. Value in Health. Published online October 22, 2021
The issue of overlapping surgery was back in the news recently with the announcement that Massachusetts General Hospital paid $14.6 million to settle a whistle-blower suit over such surgeries (Saltzman 2022). This settlement went to insurers for presumed improper billing. It actually was the third payment made by the MGH regarding the overlapping surgeries. In 2019 the MGH settled for $13 million with a physician who challenged double-booked surgeries (Saltzman 2019a). That surgeon had been fired by the MGH in 2015 for allegedly violating patient confidentiality, but he always believed he had been dismissed for raising safety concerns about colleagues who performed two operations at once. MGH also offered him his old job back to settle his wrongful termination lawsuit (which he declined) and agreed to honor him with a hospital safety initiative in his name. The third settlement was with former Boston Red Sox pitcher Bobby Jenks to settle a claim that he suffered a career-ending spine injury when a surgeon at the MGH operated on his back while overseeing another operation at the same time (Saltzman 2019b). According to Saltzman, the three out-of-court settlements total $32.7 million.
As part of the current settlement, the Mass General Brigham healthcare system agreed to change its consent forms to include the wording "My surgeon has informed me that my surgery is scheduled to overlap with another procedure she/he is scheduled to perform. I understand that this means my surgeon will be present in the operating room during the critical parts of my surgery but may not be present for my entire surgery." (Putka 2022).
The controversial practice first received national attention in 2015 when the Boston Globe Spotlight team published a series on it (Abelson 2015). We’ve taken a strong position against overlapping surgery, beginning with our November 10, 2015 Patient Safety Tip of the Week “Weighing in on Double-Booked Surgery”.
Over the years, there have been many articles and studies defending the practice (see our Patient Safety Tips of the Week for March 12, 2019 “Update on Overlapping Surgery” and December 3, 2019 “Overlapping Surgery Back in the News”). Most have looked at mortality rates and complication rates in large databases and concluded that there is no statistical difference between cases with or without an overlap. We have pointed out that complications due to overlapping surgery are still quite rare, so statistics from any large databases will “dilute out” those cases that did have complications. Those of us involved in patient safety have all seen instances in which overlapping surgery was a contributing factor to or root cause of an adverse event.
Our December 19, 2017 Patient Safety Tip of the Week “More on Overlapping Surgery” had our detailed comments on the following considerations for overlapping surgery:
We hope you’ll go back to that column (and all our columns listed below) to see our arguments against the practice of overlapping surgery. However, even though we personally would not consent to undergo overlapping surgery, we are pragmatic and understand the practice is not likely to go away any time soon. Therefore, we developed our “Overlapping Surgery Checklist” to help guide you in planning for safe implementation.
Part of our job in teaching hospitals is to train surgeons and other physicians to be able to practice independently. That obviously requires graded autonomy. Since the onset of the COVID-19 pandemic there has been a reduction in the number of elective surgeries performed at many hospitals, reducing the learning opportunities for surgical residents and fellow. So now, more than ever, we need to foster graded surgical autonomy. A recemt study from the VA health system (Oliver 2021) showed that surgical procedures performed by residents alone were not associated with any changes in all-cause mortality or composite morbidity compared with those performed by attending surgeons alone or by residents with the assistance of attending surgeons. The accompanying editorial (Stulberg 2021) notes that lack of attending surgeon scrubbed and resident autonomy are not equivalent. It notes that, outside of technical assistance, attending faculty may also coach residents regarding next steps or provide advice to avoid missteps.
But the issue comes down to transparency. If a patient is expecting that the attending surgeon will be performing the entire surgery or at least be present in the OR for the entire surgery, the informed consent must clearly specifiy anything to the contrary.The revised MGH informed consent wording should convey the appropriate message to the patient, assuming the patient has the opportunity to discuss the details and implications of the attending surgeon’s absence from any portion of the surgery or procedure.
See our previous columns on double-booked, concurrent, or overlapping surgery:
And our “Overlapping Surgery Checklist”
Saltzman J. Mass. General pays $14.6 million to settle whistle-blower suit over concurrent surgeries. Hospital’s third major payment related to surgeons doing two operations at once. Boston Globe 2022; February 18, 2022
Saltzman J. MGH settles for $13m with doctor who challenged double-booked surgeries. Boston Globe 2019; November 7, 2019
Saltzman J. Former Red Sox pitcher settles claim with doctor, MGH for $5.1 million. Boston Globe 2019; May 8, 2019
Putka S. Mass General 'Not an Outlier' in Double-Booked Surgeries — The teaching hospital resolves lawsuit, changes patient consent forms. MedPage Today 2022; February 24, 2022
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015
Oliver JB, Kunac A, McFarlane JL, Anjaria DJ. Association Between Operative Autonomy of Surgical Residents and Patient Outcomes. JAMA Surg 2021; Published online December 22, 2021
Stulberg JJ, Adams SD, Kao LS. Lack of Attending Surgeon Scrubbed and Resident Autonomy Are Not Equivalent. JAMA Surg 2021; Published online December 22, 2021
We’ve done many columns on problems associated with intrahospital transports (see list at the end of today’s column), but only one specifically on interhospital transfers or transports (our October 30, 2018 Patient Safety Tip of the Week “Interhospital Transfers”). Of course, many of the same problems seen during intrahospital transports may also occur during interhospital tansfers but there are additional considerations.
A recent Norwegian study of interhospital transports of critically ill patients (Eiding 2022) revealed a very high number of incidents. Despite this fact, these incidents are severely underreported in the hospital’s electronic incident reporting system. This suggests that learning is lost and errors with predominant probability are repeated. These results emphasize the existing challenges in regard to the quality and safety of interhospital transport of critically ill patients.
Personnel involved in interhospital transports of critically ill patients for 2 services filled out forms after each transport for 8 and 12 months, respectively. Service A reported incidents during 48% of their transports, with up to 7 unique incidents reported during a single transport. Service B reported incidents during 49% of their transports, with up to 4 unique incidents during a single transport. There was an average of 0.65 unique incidents per transport. These occurred “during loading” (30%), “during transport” (35%), and “during handover” (35%), with some of the incidents occurring in more than one
phase of the transport. Incidents were categorized as medical (15%), technical (25%), missing equipment (17%), and personal failures and communication difficulties (42%). But only 3 (1%) of the 294 unique incidents were actually reported in the hospital’s electronic incident reporting system.
A group of senior prehospital physician experts evaluated the materials, and were asked to consider which incidents should have been reported in the hospital’s electronic incident reporting system and suggest an intervention to avoid the incident in the future. The expert group advised that 28 (10%), 33 (11%), and 250 (85%) of the registered incidents should have been reported in the hospital’s electronic incident reporting system.
There was considerable variability among the three expert reviewers in terms of significance of both the severity and reportability of the incidents. Quite frankly, that wide variability among the three expert reviewers makes interpretation of the study difficult. But the main conclusion, that incidents are common during interhospital transports of critically ill patients and are significantly underreported, probably holds true. The authors stress that important lessons may be missed, and system errors likely have a high probability of being repeated. Thus, an opportunity to make the process safer may be missed. Service quality and transport safety also may be overrated.
We hope you will go back to our October 30, 2018 Patient Safety Tip of the Week “Interhospital Transfers” for an extensive discussion of the types of incidents that occur during interhospital transports and transfers. Other lessons are in our many columns on intrahospital transports and those on medical air transports.
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
Our prior columns dealing with medical helicopter issues:
July 8, 2008 “Medical Helicopter Crashes”
October 2008 “More Medical Helicopter Crashes”
February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
December 29, 2015 “More Medical Helicopter Hazards”
October 30, 2018 “Interhospital Transfers”
Eiding H, Røise O, Kongsgaard UE. Potentially Severe Incidents During Interhospital Transport of Critically Ill Patients, Frequently Occurring But Rarely Reported: A Prospective Study. Journal of Patient Safety 2022; 18(1): e315-e319
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