Complications and 30-Day readmission rates after craniotomy/craniectomy: A single Institutional study of 243 consecutive patients

Acute hyponatremia post craniotomy resulting in a unilateral fixed and dilated pupil: A case study on diagnosis and management

Background

Postoperative hyponatremia is a known complication of intracranial surgery, which can present with depressed mental status. Hyponatremia resulting in focal neurologic deficits is less frequently described.

Case Description

We describe a patient who, after a bifrontal craniotomy for olfactory groove meningioma, developed acute hyponatremia overnight with a decline in mental status from Glasgow coma scale (GCS) score 15 to GCS 7 and a unilateral fixed dilated pupil. Head computed tomography showed expected postoperative changes without new acute or localizing findings, such as unilateral uncal herniation. The patient's mental status and pupil immediately improved with the administration of mannitol; however, there was a subsequent decline in mental status with a preserved pupil later that morning. Hypertonic saline reversed the neurologic change, and the patient was eventually discharged without a neurologic deficit. Focal neurologic deficits need not always arise following a craniotomy from a postoperative hematoma, stroke, or other finding with radiographic correlate.

Conclusion

Post-craniotomy hyponatremia should now be seen as a postoperative complication that can result in both a general neurologic decline in mental status, as well as with focal neurologic signs such as a fixed, dilated pupil, which can be reversed with hyperosmolar therapy and correction of the hyponatremia.

Results of a Pilot Study for a Pharmacy Discharge Review in Neurosurgical Patients: A Quality-Safety Initiative

Objective A multidisciplinary collaboration between the neurosurgical team and the pharmacy was established to conduct a pilot study in which discharged neurosurgical patients from a community hospital would receive medication reconciliation services and counseling by a pharmacy specialist to determine the impact on patient safety, readmission rates, and medication compliance. Methods Pharmacists reviewed discharge medication reconciliations of neurosurgical patients to address any discrepancies with the nurse practitioners or physicians prior to discharge and provided discharge medication counseling to the patient/families at the bedside. The service was provided on weekdays during the eight-hour pharmacist shift in addition to other daily responsibilities. Data were analyzed by type and the total number of pharmacy interventions encountered during the discharge medication reconciliation process, time to complete services, and readmission rates. Lastly, the discharged neurosurgical patients that were not seen by pharmacists during the one-month pilot study were reviewed retrospectively to determine potential interventions. Results A total of 48 neurosurgical patients were discharged during the one-month pilot study; 27 patients received discharge medication reconciliation services and counseling from the pharmacy specialists. Sixty-three pharmacy interventions were accepted with prevention of medication errors/adverse drug reactions (21%, n=21) and addition of missing medication (21%, n=21) being the most common intervention types. The mean time to complete the services was 27 minutes and there was one non-medication-related readmission of the 27 patients seen. Twenty-one neurosurgical patients who were discharged without receiving services were reviewed retrospectively. It was determined that there was a potential for another 64 pharmacy interventions in which clarification of indication (33%, n=21) was the most common intervention type, followed by prevention of medication errors/adverse drug reactions (25%, n=16) and addition of missing medication (22%, n=14). There was a total of one medication-related readmission of the 21 patients not seen by the pharmacist during the pilot study. Conclusion The collaboration of pharmacists in the discharge process benefits neurosurgical patients by reducing the number of discrepancies when transitioning home and provides an additional layer of safety to reduce medication errors and/or prevent adverse events.

The Relation of Surgical Procedures and Diagnosis Groups to Unplanned Readmission in Spinal Neurosurgery: A Retrospective Single Center Study

Background: Unplanned readmission has gained increasing interest as a quality marker for inpatient care, as it is associated with patient mortality and higher economic costs. Spinal neurosurgery is characterized by a lack of epidemiologic readmission data. The aim of this study was to identify causes and predictors for unplanned readmissions related to index diagnoses and surgical procedures. Methods: In this study, from 2015 to 2017, spinal neurosurgical procedures were recorded for surgical and non-surgical treated patients. The main reasons for an unplanned readmission within 30 days following discharge were identified. Multivariate logarithmic regression revealed predictors of unplanned readmission. Results: A total of 1172 patient records were examined, of which 4.27% disclosed unplanned readmissions. Among the surgical patients, the readmission rate was 4.06%, mainly attributable to surgical site infections, while it was 5.06% for the non-surgical patients, attributable to uncontrolled pain. A night-time surgery presented as the independent predictive factor. Conclusion: In the heterogeneous group of spinal neurosurgical patients, stratification into diagnostic groups is necessary for statistical analysis. Degenerative lumbar spinal stenosis and spinal abscesses are mainly affected by unplanned readmission. The surgical procedure dorsal root ganglion stimulation is an independent predictor of unplanned re-hospitalizations, as is the timing of surgery.

Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate differences in 30- and 90-day readmissions for spine metastases treated with decompression and/or fusion spine surgery in a nationwide readmission database.

SUMMARY OF BACKGROUND DATA

Patients with metastases to the spine represent a particularly vulnerable patient group that may encounter frequent readmissions. However, the 30- and 90-day rates for readmission following surgery for spine metastases have not been well described.

METHODS

The Nationwide Readmission Database years 2013 to 2015 was queried. Patients were grouped by no readmission (non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Weighted multivariate analysis assessed impact of treatment approach and clinical factors associated with 30- and 90-day readmissions.

RESULTS

There were a total of 4423 patients with a diagnosis of spine metastases identified who underwent spine surgery, of which 1657 (37.5%) encountered either a 30-or 90-day unplanned readmission (30-R: n = 1068 [24-.1%]; 90-R: n = 589 [13.3%]; non-R: n = 2766). The most prevalent inpatient complications observed were postoperative infection (30-R: 16.3%, 90-R: 14.3%, non-R: 11.5%), acute post-hemorrhagic anemia (30-R: 13.4%, 90-R: 14.2%, non-R: 14.5%), and genitourinary complication (30-R: 5.7%, 90-R: 2.9%, non-R: 6.2%). The most prevalent 30-day and 90-day reasons for admission were sepsis (30-R: 10.2%, 90-R: 10.8%), postoperative infection (30-R: 13.7%, 90-R: 6.5%), and genitourinary complication (30-R: 3.9%, 90-R: 4.1%). On multivariate regression analysis, surgery type, age, hypertension, and renal failure were independently associated with 30-day readmission; rheumatoid arthritis/collagen vascular diseases, and coagulopathy were independently associated with 90-day readmission.

CONCLUSION

In this study, we demonstrate several patient-level factors independently associated with unplanned hospital readmissions after surgical treatment intervention for spine metastases. Furthermore, we find that the most common reasons for readmission are sepsis, postoperative infection, and genitourinary complications.Level of Evidence: 3.

Tobacco Use Is Associated with Readmission within 90 Days after Craniotomy

OBJECTIVE

Tobacco use increases morbidity and mortality following craniotomy. Readmission is an important hospital metric of patient outcomes and has been used to inform reimbursement. This study aims to determine if tobacco use is associated with readmission within 90 days of hospital discharge among patients undergoing elective craniotomy.

METHODS

The Nationwide Readmissions Database (NRD), a population-based, nationally representative database, was queried from 2010-2014. Patients undergoing craniotomy for benign or malignant tumors, vascular pathologies, and epilepsy were identified. Readmissions within 90 days of index hospitalization were characterized by admitting diagnoses. Tobacco use was defined by ICD-9 coding for active or prior use. Descriptive and multivariable regression analyses evaluated patient and hospital factors associated with readmission.

RESULTS

The study population included 77,903 patients treated with craniotomy. Of these, 17,674 (22.6%) were readmitted within 90 days. The most common reasons for readmission were post-operative infection (5.8%), septicemia (4.2%), pulmonary embolism (3.9%), and pneumonia (2.9%). Tobacco use was associated with a 7% increased likelihood of 90-day readmission (OR 1.07, 95% CI 1.03-1.11, p = 0.0008) after accounting for other patient-, disease-, and hospital-level factors in multivariate analysis.

CONCLUSIONS

Tobacco use was associated with increased 90-day readmission in patients undergoing craniotomy. Recognizing tobacco use as a modifiable risk factor of readmission presents an opportunity to identify susceptible patients.

A cross-sectional analysis of variables associated with morbidity and mortality in postoperative neurosurgical patients diagnosed with sepsis

BACKGROUND

Sepsis is a systemic, inflammatory response to infection associated with significant morbidity and mortality. There is a considerable lack of literature exploring sepsis in neurosurgery. We aimed to identify variables that were correlated with mortality and increased morbidity as defined by readmission and increased length of stay in postoperative neurosurgical patients that met a sepsis diagnosis.

METHODS

A retrospective chart review was conducted of 105 patients who underwent a neurosurgical operation at our institution from 2012 to 2017 who were discharged with at least one sepsis diagnosis code and who did not have a preoperative infection. We identified variables that were correlated with mortality, readmission, and increased length of stay.

RESULTS

Patients who survived were preferentially distributed towards lower ASA Physical Status Classification scores. A larger percentage of patients who did not survive had cranial surgery, whereas patients who survived were more likely to have undergone spinal surgery. Higher respiratory rates, higher maximum lactic acid levels, positive sputum cultures, and lower incoming Glasgow Coma Scores (GCS) were significantly correlated with mortality. A larger fraction of readmitted patients had positive surgical site cultures but had negative sputum cultures. Length of hospitalization was correlated with incoming GCS, non-elective operations, and Foley catheter, arterial line, central line, and endotracheal tube duration.

CONCLUSIONS

Neurosurgical postoperative patients diagnosed with sepsis may be risk stratified for mortality, readmission, and increased length of stay based on certain variables that may help direct their care. Further prospective studies are needed to explore causal relationships.

Perioperative fluid balance and 30-day unplanned readmission after lung cancer surgery: a retrospective study

Background

Perioperative positive fluid balance (FB) is associated with increased complications after lung resection surgery. However, its impact on the 30-day unplanned readmission rate is unclear. This study aimed to determine whether perioperative FB status during and up to 24 hours after lung resection surgery is associated with the 30-day unplanned readmission rate.

Methods

This retrospective cohort study examined adult patients aged 19 years or older who underwent lung cancer surgery at a single tertiary academic hospital between January 2005 and February 2018. Weight-based cumulative FB (%) was calculated during and up to 24 hours after surgery and was categorized as positive (≥5%), normal (0-5%), or negative (<0%). Univariable and multivariable logistic regression analyses were performed.

Results

The final analysis included 2,412 patients; 164 patients had unplanned readmission during the first 30 postoperative days (6.9%; 164/2,412). According to the multivariable logistic regression model, the positive FB group had a 2.42-time higher risk of 30-day unplanned readmission compared to the normal FB group [odds ratio (OR): 2.42; 95% confidence interval (CI): 1.20 to 4.89; P=0.014]. However, the risk of the negative FB group did not significantly differ from that of the normal FB group (OR: 1.20; 95% CI: 0.46 to 3.12; P=0.711).

Conclusions

Perioperative positive FB (>5%) during and up to 24 hours after surgery was associated with an increased 30-day unplanned readmission rate after lung cancer surgery. Future prospective studies are needed to confirm these findings.

Causes of hospital readmissions within 7 days from the neurosurgical service of a quaternary referral hospital

Background:

Evaluation of readmission rates as a proxy metric of health-care quality in neurological surgery has grown to become a prevalent area of investigation in the last several years. Significant attention has been paid to 30-day readmission rates due to the financial incentive to health-care providers following the enforcement of the penalties created by the Affordable Care Act. However, relatively little attention has been paid to patients readmitted within 7 days of discharge to large quaternary neurological surgery services. This study was conducted to examine the causes and unique characteristics of 7-day readmission rates from a neurosurgical service at a large quaternary referral hospital.

Methods:

A retrospective observational analysis of all 7-day readmissions to the neurosurgical surgery service of the University of Pittsburgh Medical Center, Presbyterian Hospital from August 2017 to June 2019, was performed. Patients were organized into seven categories based on their primary reason for readmission: scheduled surgeries, infection, pain, altered mental status or seizures, general postoperative complications, complications directly resulting from a neurosurgical intervention, and unrelated reasons. Demographic information, the time between initial discharge and subsequent readmission, and discharge disposition were also recorded.

Results:

Of 5274 discharges, 258 patients (4.9%) were readmitted within 7 days (55.0% male; mean age 60 years of age). Two-thirds of patients readmitted initially underwent care for cranial pathologies (57% of 258 patients) as opposed to a third for spine pathologies (33% of 258 patients). Complications that directly arose from the neurosurgical intervention (e.g., shunt infection or misplacement, and hardware misplacement) represented 18.9% of total readmission, while general postoperative complications (e.g., urinary tract infection) accounted for 15.1% of total readmission, in which all together were slightly greater than a third of readmissions. Seizures or altered mental status led to less than a fifth of readmissions (17.0%), followed by readmissions from unrelated diagnosis or miscellaneous reasons (17.0%) and scheduled surgeries (13.1%). Taken together, surgical site infections (9.7%) and postoperative pain (9.3%) accounted for 9.7% and 9.3 % of readmissions, respectively.

Conclusion:

Approximately 5% of patients discharged in a single year from our quaternary referral center were readmitted within 7-days. Approximately 90% of all 7-day readmissions were unplanned, with one-third resulting directly from perioperative complications. Further investigation to better understand this acutely vulnerable yet previously overlooked population may guide focused efforts to increase the quality of neurosurgical patient care.

Safety and costs analysis of early hospital discharge after brain tumour surgery: a pilot study

BACKGROUND

A daily algorithm for hospital discharge (DAHD) is a key point in the concept of Enhanced Recovery After Surgery (ERAS) protocol. We aimed to evaluate the length of stay (LOS), rate of complications, and hospital costs variances after the introduction of the DAHD compared to the traditional postoperative management of brain tumour patients.

METHODS

This is a cohort study with partial retrospective data collection. All consecutive patients who underwent brain tumour resection in 2017 were analysed. Demographics and procedure-related variables, as well as clinical outcomes, LOS and healthcare costs within 30 days after surgery were compared in patients before/pre-implementation and after/post-implementation the DAHD, which included: stable neurological examination; oral feeding without aspiration risk; pain control with oral medications; no intravenous medications. The algorithm was applied every morning and discharge was considered from day 1 after surgery if criteria was fulfilled. The primary outcome (LOS after surgery) analysis was adjusted for the preoperative performance status on a multivariable logistic regression model.

RESULTS

A total of 61 patients were studied (pre-implementation 32, post-implementation 29). The baseline demographic characteristics were similar between the groups. After the DAHD implementation, LOS decreased significantly (median 5 versus 3 days; p = 0.001) and the proportion of patients who were discharged on day 1 or 2 after surgery increased (44.8% vs 3.1%; p < 0.001). Major and minor complications rates, readmission rate, and unplanned return to hospital in 30-day follow-up were comparable between the groups. There was a significant reduction in the median costs of hospitalization in DAHD group (US$2135 vs US$2765, p = 0.043), mainly due to a reduction in median ward costs (US$922 vs US$1623, p = 0.009).

CONCLUSIONS

Early discharge after brain tumour surgery appears to be safe and inexpensive. The LOS and hospitalization costs were reduced without increasing readmission rate or postoperative complications.

Smoking and Obesity are Risk Factors for Thirty-Day Readmissions Following Skull Base Surgery

Background  Thirty-day readmission has become a significant health care metric reflecting the quality of care and on the cost of service delivery. There is little data on the impact of complications following skull base surgery (SBS) on emergency readmission. Identifying modifiable risk factors for readmission may improve care and reduce cost. Design  The study was designed as a single-center retrospective cohort study. Methods  Records for a consecutive series of 165 patients who underwent open or endoscopic SBS by a single surgeon reviewed. Patients with pituitary adenoma were excluded. The diagnosis, procedure, complications, length of stay (LOS), body mass index (BMI), and smoking status were recorded. Readmission to the neurosurgical department or regional hospitals was either noted prospectively or the patient contacted. Cause and length of readmission was documented. Results  Of the 165 cases, 14 (8.5%) were readmitted within 30 days. Causes for readmission included cerebrospinal fluid (CSF) leak in 5/14 or 35.7% (overall rate for readmission for this complication in the series is 3.1%), infection in 4/14 (28.6%), hyponatraemia in 2/14 (14.3%), vascular: sinus thrombosis in 1/14 (7.1%), seizures in 1/14 (7.1%), and epistaxis in 1/14 (7.1%). Initial and readmission LOS was 6 and 14 days, respectively. BMI was higher in those readmitted within 30 days (33.2 kg/m ² ) versus no readmission (27.1 kg/m ² ). In addition, of those readmitted within 30 days, 35.7% were smokers compared with 20.8% in those not readmitted. Conclusion  In this series, smoking and raised BMI may be indicators for within 30-day readmission and complications in this population, raising the question of risk factor modification prior to elective intervention.