Adverse events and readmissions after day-case urological surgery

Unplanned hospital admissions within 24 h after 53,185 surgical procedures at a U.S. ambulatory surgery center

BACKGROUND

Unplanned admission after surgery at an ambulatory surgery center (ASC) is an established measure of the quality of care and can affect the patient's experience. Previous studies on this topic are generally dated, focused on a single specialty, or studied 30-day admissions after ambulatory surgery. Few studies have reported admission within 24 h after surgery at an ASC which is a different but important measure of the quality of anesthetic and surgical care. Understanding admissions within 24 h of surgery can identify opportunities for improvement immediately after surgery. Therefore, our study was designed to assess the incidence and risk factors for unplanned hospital admissions within 24 h after surgery performed at a hospital ASC.

METHODS

After Institutional Review Board approval, a retrospective analysis was performed on all adult patients who underwent surgery at a US ASC between January 1, 2016, and December 31, 2022. Data were obtained from the hospital's electronic medical record. The study sample was divided into two groups: those with an unplanned hospital admission within 24 h after surgery and those without an unplanned hospital admission. To evaluate risk factors for unplanned hospital admissions, univariate analyses with p value < 0.05 were utilized to identify significant patient variables related to hospital admissions. These variables were further adjusted using a multivariable Firth logistic regression. Descriptive statistics were used to explore the number of patients in different variable categories.

RESULTS

Overall, 53,185 cases were identified for the 7-year period. The incidence of unplanned hospital admission over this period was 0.09% (95% CI 0.07-0.1122%; ranging from 0.05 to 0.12% per year. In the multivariable model, surgery duration (OR 1.010, 95% CI 1.007-1.012, p value < 0.0001), peripheral vascular disease (OR 14.489, 95% CI 4.862-43.174, p value < 0.0001), and deep venous thrombosis (OR 5.527, 95% CI 1.909-16.001, p value = 0.0016) were significantly associated with unplanned hospital admission.

CONCLUSION

The overall incidence of unplanned hospital admission after surgery at a large tertiary care ambulatory surgery center is very low. This admission rate can also serve as a reference point for future studies and quality improvement initiatives.

[Evaluation of spinal anesthesia in urological outpatient surgery, comparison between two local anesthetics (Chloroprocaine/Bupivacaine)]

INTRODUCTION

Spinal anesthesia in outpatient urology is controversial (longer hospital stay, risk of urinary retention). The main goal was to evaluate outpatient spinal anesthesia and to compare 2 local anesthetics secondarily.

MATERIAL

Monocentric retrospective study including all patients undergoing surgery in urological ambulatory surgery under spinal anesthesia between December 2011 and May 2015, split into two groups according to the local anesthetic used: bupivacaine (BP) and chloroprocaine (CP). Quantitative variables were compared by Student's t-test, qualitative variables by χ² test.

RESULTS

Seventy-one (95%) out of the 75 patients included have been discharged the same day. Discharge was impossible in these cases: patient alone at home (1), bladder clot (1), JJ intolerance (1), delayed micturition (1). The mean duration of the procedure was 27±19min, the SSPI's was 55±31min, the stay's was 360±91min. A total of 45 patients (60%) received BP and 30 (40%) received CP. The mean residence time in SSPI was significantly reduced in the CP group (47±24min vs. 61±34min, P=0.04). One patient experienced urination delay in the BP group with no significant difference. No significant difference for the other criteria studied despite the mean age, which is higher in the CP group (P=0.02).

CONCLUSION

Spinal anesthesia is adapted to ambulatory urology, and does not increase the risk of urinary retention, especially with CP that would decrease the length of stay in SSPI compared to BP.

LEVEL OF EVIDENCE

4.

Reasons for early readmission after percutaneous nephrolithotomy and retrograde intrarenal surgery

Introduction

Hospital readmissions are frequent and costly. In many countries health governors focus on unplanned postsurgical hospital readmissions as an objective metric for quality of care.

Aim

To investigate the rate of readmissions after retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) operations, classify these factors, define the higher risk patients for readmission and develop prevention strategies.

Material and methods

A historical cohort study was conducted for a period of 36 months, between 2013 and 2016. A total of 471 consecutive patients, of whom 177 had PCNL (37.6%) and the remaining 294 had RIRS (62.4%), were included. The two groups were compared in terms of stone burden, previous stone treatments, initial symptoms, ASA class, intra-operative complications, post-operative stenting, and drugs prescribed at discharge, so as to find the factors influencing the readmission rate for both groups.

Results

The PCNL operation was found to have a significantly higher risk for readmission when compared to RIRS (27.1% vs. 20.4%, respectively, p = 0.0041). Perioperative complications (p = 0.002 for PCNL and p = 0.001 for RIRS), residual stone(s) or fragments after the operation (p = 0.002 for PCNL and p = 0.001 for RIRS) significantly increased the readmission rate in both groups. The readmission rates were individually affected by postoperative JJ stent placement in the PCNL group (p = 0.001) and previous stone treatments for the RIRS group (p = 0.001).

Conclusions

Readmission rates were higher in the PCNL group, but the influencing factors were similar for both groups. The presence of multiple stones preoperatively and residual stones or fragments postoperatively are the most important risk factors for early re-admission after PCNL and RIRS.

Care Complexity Individual Factors Associated With Hospital Readmission: A Retrospective Cohort Study

PURPOSE

To determine the frequency of care complexity individual factors documented in the nursing assessment and to identify the risk factors associated with hospital readmission within 30 days of hospital discharge.

DESIGN

Observational analysis of a retrospective cohort at a 700-bed university hospital in Barcelona, Spain. A total of 16,925 adult patient admissions to a ward or intermediate care units were evaluated from January to December 2016. Most patients were admitted due to cardiocirculatory and respiratory disorders (29.3%), musculoskeletal and nervous system disorders (21.8%), digestive and hepatobiliary conditions (17.9%), and kidney or urinary disorders (11.2%).

METHODS

Readmission was defined as rehospitalization for any reason within 30 days of discharge. Patients who required hospital readmission were compared with those who did not. The individual factors of care complexity included five domains (developmental, mental-cognitive, psycho-emotional, sociocultural, and comorbidity or complications) and were reviewed using the electronic nursing assessment records. Multivariate logistic analysis was performed to determine factors associated with readmission.

FINDINGS

A total of 1,052 patients (6.4%) were readmitted within 30 days of hospital discharge. Care complexity individual factors from the comorbidity or complications domain were found to be the most frequently e-charted (88.3%). Care complexity individual factors from developmental (33.2%), psycho-emotional (13.2%), mental-cognitive (7.2%), and sociocultural (0.7%) domains were less frequently documented. Independent factors associated with hospital readmission were old age (≥75 years), duration of first hospitalization, admission to a nonsurgical ward, major chronic disease, hemodynamic instability, immunosuppression, and relative weight of diagnosis-related group.

CONCLUSIONS

A substantial number of patients required readmission within 30 days after discharge. The most frequent care complexity individual factors recorded in the nursing assessment at index admission were related to comorbidity or complications, developmental, and psycho-emotional domains. Strategies related to transition of care that include clinical characteristics and comorbidity or complications factors should be a priority at hospital discharge and after leaving hospital, but other factors related to developmental and psycho-emotional domains could have an important effect on the use of healthcare resources.

CLINICAL RELEVANCE

Nurses should identify patients with comorbidity or complications, developmental, and psycho-emotional complexity factors during the index admission in order to be able to implement an effective discharge process of care.

Predicting procedural pain after ureteroscopy: does hydrodistention play a role?

Purpose:

To identify perioperative predictors of immediate pain after ureteroscopy, specifically evaluating the impact of hydrodistention from irrigation on pain.

Materials and Methods:

We retrospectively identified patients who underwent ureteroscopy for the treatment of calculi. Data recorded for these patients included their maximum pain score in the post-anesthesia care unit (PACU), average flow rate of irrigant used during the procedure, patient and stone characteristics, operative procedure, and details of patients' immediate, post-operative course. Spearman's rho was used to determine the relationship between non-parametric, continuous variables. Then, a linear regression was performed to assess which variables could predict the peak pain score.

Results:

A total of 131 patients were included in the study. A non-parametric correlation analysis revealed that maximum pain score was negatively correlated with being male (r = −0.18, p=0.04), age (r = −0.34, p<0.001), and post-op foley placement (r = −0.20, p=0.02) but positively correlated with the preoperative pain score (r = 0.41, p<0.001), time in the PACU (r = 0.19, p = 0.03), and the morphine equivalent dose (MED) of narcotics administered in the PACU (r = 0.67, p<0.001). On linear regression, the significant variables were age, preoperative pain score, and stent placement. For every ten-year increase in age post-operative pain score decreased by 4/10 of a point (p = 0.03). For every 1 point increase in preoperative pain score there was a 3/10 of a point increase in the maximum pain score (p = 0.01), and leaving a stent in place post-operatively was associated with a 1.6 point increase in the maximum pain score.

Conclusions:

Hydrodistention does not play a role in post-ureteroscopy pain. Patients who are younger, have higher preoperative pain scores, or who are stented will experience more post-operative pain after ureteroscopy.

Factors influencing unexpected disposition after orthopedic ambulatory surgery

STUDY OBJECTIVE

To analyze whether patient characteristics, ambulatory facility type, anesthesia provider and technique, procedure type, and temporal factors impact the outcome of unexpected disposition after ambulatory knee and shoulder surgery.

DESIGN

Retrospective analysis of a national database.

SETTING

Freestanding and hospital-based ambulatory surgery facilities.

MEASUREMENTS

Ambulatory knee and shoulder surgery cases from 1996 and 2006 were identified through the National Survey of Ambulatory Surgery. The incidence of unexpected disposition status was determined and risk factors for such outcome were analyzed.

MAIN RESULTS

Factors independently increasing the risk for unexpected disposition included procedures performed in hospital-based versus freestanding facilities [odds ratio (OR) 6.83 (95% confidence interval [CI] 4.34; 10.75)], shoulder versus knee procedures [OR 3.84 (CI 2.55; 5.77)], anesthesia provided by nonanesthesiology professionals and certified registered nurse-anesthetists versus anesthesiologists [OR 7.33 (CI 4.18; 12.84) and OR 1.80 (CI 1.09; 2.99), respectively]. Decreased risk for unexpected disposition was for procedures performed in 2006 versus 1996 [OR 0.15 (CI 0.10; 0.24)] and the use of anesthesia other than regional or general [OR 0.34 (CI 0.18; 0.68)].

CONCLUSIONS

The decreased risk for unexpected disposition associated with more recent data and with freestanding versus hospital-based facilities may represent improvements in efficiency, while the decreased odds for such disposition status associated with the use of other than general or regional anesthesia may be related to a lower invasiveness of cases. We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. No difference in this outcome was noted when an anesthesia care team provided care.

Immediate unplanned hospital admission after outpatient ureteroscopy for stone disease

PURPOSE

Medicare recently changed reimbursement for ureteroscopy, encouraging migration to ambulatory surgical centers. To our knowledge the risk of immediate unplanned hospital admission, which may discourage ureteroscopy at ambulatory surgical centers, is unknown. We determined the rate of immediate unplanned hospital admission, identified factors associated with admission and developed a risk stratification tool to assist with location selection for outpatient ureteroscopy.

MATERIALS AND METHODS

We retrospectively reviewed the records of 1,798 consecutive outpatient ureteroscopic procedures for urolithiasis performed from 1998 to 2008 at our institution. Patients requiring immediate hospital admission were matched 1 to 3 by provider, gender and date with controls who did not require admission. Patient demographics, comorbid conditions, stone history and burden, and operative technique were assessed for impact on admission by bivariate and multivariate logistic regression. A scoring system was developed and estimated admission rates were calculated.

RESULTS

There were 70 immediate unplanned admissions (3.9%). Based on multivariate analysis the factors associated with unplanned admission were any previous admission related to stones (p <0.001), history of psychiatric illness (p = 0.016) and bilateral procedure (p = 0.019). Patients with distal ureteral stones were less likely to require admission (p = 0.026). One point was added for each positive factor and 1 was subtracted for a distal ureteral stone. A risk factor score of 2 or greater in 9% of the cohort was associated with an estimated 20.0% admission rate while lower scores in 91% of the cohort were associated with a 2.9% admission rate.

CONCLUSIONS

Readily identifiable factors can stratify the risk of unplanned hospital admission and help guide the selection of the most appropriate facility for outpatient ureteroscopy.