Understanding unplanned readmissions for children undergoing surgery in a single pediatric general surgical department

Recently, hospital readmission, the important metric for the quality measurement of patient care, was pushed forward due to pressure linked to payment [1‐3]. Furthermore, a patient’s unplanned readmission influences their quality of life and limits hospital resources. In 2008, the Medicare Payment Advisory Commission in the USA conducted payment reforms to encourage a reduction in unnecessary surgical readmissions and save health care costs [4, 5].

For surgical patients, the postoperative complications were the most reasons related to hospital readmission, which is fundamentally different from medical patients [6]. Because specific procedures carry high readmission risk, the causes of readmission for surgical patients are often associated with underlying surgical conditions, suggesting that there is an opportunity to identify the patients who carry the risk of readmission postoperatively and intervene this risk preoperatively.

Many studies have been carried out to investigate the risk profiles of readmission within precise patient populations, including older age patients [7‐9]. These previous studies highlight that the readmissions might be preventable with comprehensive preoperative and postoperative care. However, there was a few research that point to unplanned surgical readmission among pediatric patients, and it was unclear whether all the reported factors carry the similar risk for surgical readmission among pediatric population.

The purpose of the current research is to examine the readmitted pediatric patients undergoing general surgical operations and define the factors related to unplanned readmission in the general surgical department among pediatric patient population.

With the increased attention placed upon readmission, it is essential to understand risk factors to deliver postoperative care for quality improvement, which has expanded to pediatric postoperative care [10‐12]. The current study represents the first investigation to explore the contributing risk factors for unplanned readmission toward the development of strategies in pediatric patients who have undergone a variety of operations in a general surgical department. We demonstrated that the unplanned readmission were associated with more operative blood loss, faced a health emergency, or had more postoperative complications. Across pediatric surgical specialties, the common reasons for unplanned readmission were postoperative ileus and adhesion, postoperative biliary tract infection and wound problems.

Our overall readmission rate of 6.9% was consistent with the previously published readmission rate of 5.2% after general surgical procedures in pediatric population [13]. In the USA, for general pediatric surgery, the unplanned readmission rates are 4.4–6.5% [14, 15]. Differences in sample size and cases in the aforementioned studies compared with the current study may account for some of the differences in the readmission rates. You know, in China, due to the economic backward and imperfect of health insurance, readmissions may be influenced because some of patients could not afford the medical expense and select discharge in advance. The self-discharged patients implied the managements were interrupted, which should be the risk for the unplanned readmission. The Pediatric National Surgical Quality Improvement Program (NSQIP-P) includes major procedures that might bias toward higher reports of readmission for increased frequency of the occurrences of postoperative complications. In the current data, the appendectomies and laparotomy operations were the most common surgeries, which were related to unplanned readmission. A similar distribution of procedures, involved in unplanned readmission was present in a number of other studies [16, 17]. Reducing readmission rates and designing interventions would be important for pediatric surgical patients. The current 1.5% of planned readmission was consistent with that reported by others [18].

For quality improvement, identification the greater risks carried by which postoperative complications would be beneficial to prevent readmissions. Our research provided a retrospective unplanned readmission review and determined the reasons for readmission. While the reasons for unplanned readmission varied by different specialty, the current research supported the conclusion that postoperative ileus and adhesion were the most common reasons for readmission within general pediatric surgery, which was similar to the reported reasons of others [13, 14]. Gastrointestinal-related causes were the most common reasons for readmission, accounting for one-third of readmissions. Consequently, the most frequently performed procedure during readmissions was enterolysis. This finding contrasts with the findings for adults, for whom surgical site infections represented the leading cause of readmission among general surgery procedures [19]. In our institute, the adhesion events were treated with cautions. Some mild obstructive symptoms were readmitted for fluid resuscitation, which might account for the current high rate of post-operative intestinal adhesions. The indication for postoperative intestinal adhesions involved fluid resuscitation as well as attitudes toward readmission warrant further investigation and present opportunities for quality improvement. After postoperative intestinal adhesions, postoperative surgical site infection (SSI) was the next most frequent cause related to readmission. Recently, it was reported that over 50% of the patients following general surgical procedure readmitted due to a SSI [20]. Additionally, an operative time greater than 4 h conferred increased risk for SSI [20]. Operative approach and the transfusion of blood products depend on clinical manifestation and surgical judgment and technique. To decrease the readmissions, multidisciplinary efforts by operative surgeon, physicians and nurses should be focused on these modifiable risk factors perioperatively.

Our study provides further evidence that operative blood loss, emergency surgery and complications are the most predictive for hospital readmissions [2, 21]. Most risk factors, such as severe condition and massive surgery, were either nonmodifiable comorbidities or markers for severe underlying illness, which is not surprising. For instance, emergency surgery was a risk factor in our study [1]. However, in this research, less intuitive factors were also associated with substantial risk, such as longer length of stay and different surgeon skill levels. We found that readmission was two times when the procedure was performed with higher level surgeons. Although some authors have not found this association, which should be a potentially causative modifiable risk factor, this finding implied that strict quality control should be undertaken in our institute. After general surgery procedures, it was identified that shorter length of stay was predisposed toward readmission in some research [22]. In fact, the current data suggested that multiple complications was associated with longer length of stay and more readmission, which was also present following bariatric surgery and colorectal surgery [23, 24]. The patient’s comorbidities should drive the longer length of stay, which might also account for the readmission increase. Implications the current finding is that many of readmissions may be avoidable in a certain part of patients, which presents an opportunity to improve quality and the delivery of outpatient care or improved educational processes in our institute. The insight obtained from readmission can help support or refute the efficacy of a protocol applied across the initial operations and develop new surgical methods in the context of regular complication control. In addition, the lessons learned can be of great value in teaching young clinicians [25].

There are limitations in certain aspects of our study. First, our study has a limitation inherent to retrospective nature wherein selection bias could be confounding, which might restrict the generalizability of the current conclusions. The current data were gathered from our single general surgical department, reflecting the experience only from our institution. Although most of patients are back to our institution for further care, some of readmittion might get into local hospitals. Thus, the current real readmission may be higher than the estimated one. Finally, the lack of readmission information for specific operation is another weakness of the current research, which might help to identify high risk of operation for readmission.

We uncovered the common reasons for unplanned readmissions at our institution, namely, infection and hemorrhage. We also identified the risk factors for unplanned readmissions following general surgery in a pediatric patient population. A standardized, well-defined registry of all unplanned readmissions classified by type of index operation is important for the care quality improvement across a large population of infants and children.