What’s New in the Patient Safety World
December 2012
Surgical Complications After Discharge
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.
References:
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.
http://jama.jamanetwork.com/article.aspx?articleid=197078
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.
http://www.sciencedirect.com/science/article/pii/S1936879811001440
Jencks SF, Williams
MV, Coleman EA.. Rehospitalizations among Patients in the Medicare
Fee-for-Service Program. NEJM 2009; 360: 1418-1428
http://content.nejm.org/cgi/content/short/360/14/1418
Kazaure HS, Roman
SA, Sosa JA. Association of Postdischarge Complications with Reoperation and
Mortality in General Surgery. Arch Surg. 2012; 147(11): 1000-1007
http://archsurg.jamanetwork.com/article.aspx?articleid=1392155
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