The impact of major intraoperative adverse events on hospital readmissions

doi:10.1016/j.amjsurg.2016.03.018

The American Journal of Surgery

Volume 213, Issue 1, January 2017, Pages 10-17

https://doi.org/10.1016/j.amjsurg.2016.03.018 Get rights and content

Highlights

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Patients experiencing major intraoperative adverse events (iAEs) are more likely to be readmitted to the hospital.
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Major iAEs are independently associated with a 2-fold increase in readmissions.
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Prevention of major iAEs should be a target for surgical quality improvement efforts.

Abstract

Background

Hospital-wide readmission rates recently became a recognized benchmarking quality metric. We sought to study the independent impact of major intraoperative adverse events (iAEs) on 30-day readmission in abdominal surgery.

Methods

The 2007 to 2012 institutional American College of Surgeons National Surgical Quality Improvement Program and administrative databases for abdominal operations were matched then screened for iAEs using the International Classification of Diseases, 9th Revision, Clinical Modification–based Patient Safety Indicator “Accidental Puncture/Laceration”. Flagged charts were reviewed to confirm the presence of iAEs. Major iAEs were defined as class 3 or above, as per our recently validated iAE Classification System. The inpatient database was queried for readmission within 30 days from discharge. Univariate and multivariable models were constructed to analyze the independent impact of major iAEs on readmission, controlling for demographics, comorbidities, American Society of Anesthesiology class, and procedure type/approach/complexity (using relative value units as proxy). Reasons for readmission were investigated using the Agency for Healthcare Research and Quality's International Classification of Diseases, 9th Revision, Clinical Modification–based Clinical Classification Software.

Results

Of 9,274 surgical procedures; 921 resulted in readmission (9.9%), 183 had confirmed iAEs, 73 of which were major iAEs. Procedures with major iAEs had a higher readmission rate compared with procedures with no iAEs [24.7% vs 9.8%, P < .001]. In multivariable analyses, major iAEs were independently associated with a 2-fold increase in readmission rates [OR = 2.17 (95% CI = 1.22 to 3.86); P = .008]; 67% of readmissions after major iAEs were caused by “complications of surgical procedures or medical care” as defined by Agency for Healthcare Research and Quality.

Conclusions

Major iAEs are independently associated with increased rates of 30-day readmission. Preventing iAEs or mitigating their effects can serve as a quality improvement target to decrease surgical readmissions.

Section snippets

Patient population

All adult patients undergoing abdominal surgery under general anesthesia in a tertiary care academic center from January 2007 to October 2012 were included.

The hospital-wide comprehensive administrative database was linked with our institutional American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, and cases captured by both the databases were selected for additional analyses.

Identification of intraoperative adverse events

The matched database was queried for episodes of “accidental puncture or

Results

Out of a total of 9,274 operations, review of operative reports “flagged” by the APL algorithm confirmed the presence of at least 1 iAE in 183 operations, 73 (40%) of which consisted of a major iAE. Out of the total cohort, 921 patients (9.9%) were readmitted.

Comments

To the best of our knowledge, this is the first study to analyze the impact of iAEs on hospital readmissions, and to suggest that major iAEs are independently associated with more than 2-fold increase in 30-day readmissions.

Previous studies have examined the impact of the AHRQ's PSIs on readmissions but did not specifically assess the relationship between iAEs and readmissions. Encinosa and Hellinger found that “technical problems” (within which APL, the PSI#15, is included) were not

Conclusion

Major iAEs are independently associated with significantly increased odds of 30-day readmission. The causes for these readmissions are largely “complications of surgical procedures or medical care”. As we attempt to improve the quality of surgical care and lower surgical readmission rates, we must recognize iAEs as an important target for our quality improvement efforts.

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Cited by (19)

A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation
2024, Journal of Surgical Research
Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done.
In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them.
Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon’s experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon.
While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.
Intraoperative Deaths: Who, Why, and Can We Prevent Them?
2022, Journal of Surgical Research
Citation Excerpt :
The absence of some aspects of basic preoperative evaluation such as electrocardiogram, chest x-ray, and cardiac consultation in a few cases was noticeable in our qualitative analysis of these IODs and raised the safety issue of adequate and thorough cardiopulmonary workup, evaluation, and optimization before surgery. Another safety consideration worth discussion is how to mitigate intraoperative adverse events to prevent IODs.19,21-32 Since the publication of the seminal report “To Err is Human” by the Institute of Medicine 2 decades ago, significant effort has been directed to study and prevent avoidable harm to patients and improve patient safety.33,34
Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns.
IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype.
Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup.
We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.
Unplanned readmission after emergency laparotomy: A post hoc analysis of an EAST multicenter study
2021, Surgery (United States)
Citation Excerpt :
In our study, we observed that malignancy, malnutrition, and poor baseline respiratory status are independent predictors of readmission after emergency laparotomy. Perioperative complications have been repeatedly linked to hospital readmission,2,9,19-22 with some literature suggesting that surgical site infections in particular account for a significant portion of these readmissions.23,24 This was also evident in our analysis, whereby wound complications doubled the odds of readmission in the emergency laparotomy patient.
Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient.
This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers enrolled all adult patients undergoing emergency laparotomies and systematically collected preoperative, operative, and 30-day postoperative variables. For the purpose of this study, we defined unplanned readmission as a readmission occurring within 30 days from discharge and one that was immediately preceded by an emergency department visit. Patients were excluded if they died during the index admission, were discharged to hospice, or were transferred to other hospitals. Predictors of unplanned readmission were evaluated using a multivariable logistic regression model, adjusting for patient demographics, comorbidities, laboratory variables, and preoperative acuity of disease variables.
A total of 1,347 patients were included, of which 234 (17.4%) had an unplanned readmission. The median patient age was 60 y, 49.4% were male, and 71.4% were white. The most common diagnoses were hollow viscus perforation (28.1%) and small bowel obstruction (24.5%). Predictors of unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, confidence interval: 1.35–3.64, P = .002], weight loss >10% in the past 6 months [odds ratio: 1.65, confidence interval: 1.07–2.54, P = .023], dyspnea at baseline [odds ratio: 1.62, confidence interval: 1.06–2.48, P = .026], wound complications [odds ratio: 2.23, confidence interval: 1.55–3.19, P < .001], and discharge to nursing homes [odds ratio: 1.68, confidence interval: 1.02–2.80, P = .044]).
Unplanned readmission after emergency laparotomies are common, especially for patients with wound complications or requiring nursing homes. These system factors are potential quality improvement targets to reduce readmissions.
Impact of Surgical Checklist on Mortality, Reoperation, and Readmission Rates in Brazil, a Developing Country, and Canada, a Developed Country
2020, Journal of Perianesthesia Nursing
To compare the mortality, reoperation, and readmission rates before and after the implementation of a surgical checklist in Brazil and Canada.
An epidemiological, retrospective study was conducted.
Preimplementation and postimplementation data were collected via patient chart reviews to determine mortality, reoperation, and readmission rates.
In Brazil, a decrease in readmission rate from 2.9% to 1.7% (P = .518) was observed after the implementation of the checklist. In Canada, reoperation rate decreased from 5.6% to 4.8% (P = .649) and mortality from 1.7% to 0.9% (P = .407) after implementation. In the Brazilian institution, patients with incomplete checklists had increased rates of readmission, from 1.4% to 2.4% (P = .671), and reoperation, from 6.8% to 10.4% (P = .232).
The use of surgical checklist did not translate into improvements in the outcomes studied after its implementation in any of the scenarios evaluated. This result is possibly justified by the socioeconomic structure of each of these settings.
Outcomes associated with hyperglycemia after abdominal aortic aneurysm repair
2019, Journal of Vascular Surgery
Citation Excerpt :
We included hospital characteristics (size and teaching facility), patients' demographics (age, sex, and race), and acute and chronic problems at the index admission (eg, chronic heart disease, diabetes, hypertension). We used the Clinical Classifications Software of the Agency for Healthcare Research and Quality to group ICD-9-CM diagnosis codes into clinically relevant conditions.14 We also used ICD-9-CM diagnosis codes documented during the admission to calculate the Charlson Comorbidity Index, a measure associated with 1-year mortality.15
We evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair.
We used diagnosis and procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) to identify patients who underwent open or endovascular repair of a nonruptured AAA from September 2008 to March 2014 from the Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo). We evaluated the association between postoperative hyperglycemia (glucose concentration >180 mg/dL) and infections, in-hospital mortality, readmission, patients' characteristics, length of hospital stay, and medications. Multivariable logistic models examined the association of postoperative hyperglycemia with in-hospital infection and mortality.
Of 2478 patients, 2071 (83.5%) had good postoperative glucose control (80-180 mg/dL), and 407 (16.5%) had suboptimal control (hyperglycemia). Patients who had postoperative hyperglycemia experienced longer hospital stays (9.5 vs 4.7 days; P < .0001), higher infection rates (18% vs 8%; P < .0001), higher in-hospital mortality (8.4 vs 1.2%; P <.0001), and more acute complications (ie, acute renal failure, fluid and electrolyte disorders, respiratory complications). After adjusting for patients' characteristics and medications, multivariable logistic regression models demonstrated that patients receiving postoperative insulin had nearly 1.6 times the odds of having an infectious complication (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.2; P = .007) than those who did not. Hyperglycemic patients had 3.5 times the odds of in-hospital mortality (OR, 3.48; 95% CI, 1.78-6.80 [P = .0003]; 2.3% vs 1.2%; P < .001). When stratified by procedure type, patients with hyperglycemia who underwent endovascular repair had nearly 2 times the odds of an infectious complication (OR, 1.85; 95% CI, 0.98-3.51; P = .05) and 7.5 times the odds of in-hospital mortality (OR, 7.54; 95% CI, 1.95-29.1; P = .003). Patients who underwent an open AAA repair and who had hyperglycemia had three times the odds of dying in the hospital (OR, 3.05; 95% CI, 1.29-7.21; P = .01).
Among patients undergoing elective AAA repair, approximately one in six had postoperative hyperglycemia. After AAA repair in patients with and without diabetes, postoperative hyperglycemia was associated with adverse events, including in-hospital mortality and infections. Compared with those who had open surgery, patients undergoing endovascular repair who had postoperative hyperglycemia had greater risk of infection and death. After controlling for insulin administration and postoperative hyperglycemia, a diabetes diagnosis was associated with lower odds of both infection and in-hospital mortality. Our study suggests that hyperglycemia may be used as a clinical marker as it was found to be significantly associated with inferior outcomes after elective AAA repair. This retrospective study, however, cannot imply causation; further study using prospective methods is needed to elucidate the relationship between postoperative hyperglycemia and patient outcomes.
Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery
2018, Journal of Surgical Education
Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs.
The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator “accidental puncture/laceration.” Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs.
A large tertiary care teaching hospital.
Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident.
A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs.
The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.

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: The authors declare no conflicts of interest.

View full text

Clinical ScienceThe impact of major intraoperative adverse events on hospital readmissions

Highlights

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patient population

Identification of intraoperative adverse events

Results

Comments

Conclusion

J Vasc Surg

J Vasc Surg

J Am Coll Surg

Ann Thorac Surg

Am J Surg

J Am Coll Surg

Surgery

J Am Coll Surg

J Am Coll Surg

Am J Surg

J Am Coll Surg

J Am Coll Surg

J Am Coll Surg

J Am Coll Surg

Rehospitalizations among patients in the Medicare fee-for-service program

N Engl J Med

Clinical Science
The impact of major intraoperative adverse events on hospital readmissions