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Godse NR, Jarmula J, Kshettry VR, Woodard TD, Recinos PF, Sindwani R. Emergency department visits following endoscopic skull base surgery: An opportunity for improvement. Int Forum Allergy Rhinol 2024; 14:613-620. [PMID: 37422726 DOI: 10.1002/alr.23237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Readmissions are major healthcare expenditures, key hospital metrics, and are often preceded by an evaluation in the emergency department (ED). The purpose of this study was to analyze ED visits within 30 days of endoscopic skull base surgery (ESBS), risk factors for readmission once in the ED, and ED-related evaluation and outcomes. METHODS Retrospective review from January 2017 to December 2022 at a high-volume center of all ESBS patients who presented to the ED within 30 days of surgery. RESULTS Of 593 ESBS cases, 104 patients (17.5%) presented to the ED following surgery within 30 days, with a median presentation of 6 days post-discharge (IQR 5-14); 54 (51.9%) patients were discharged while 50 (48.1%) were readmitted. Readmitted patients were significantly older than discharged patients (median 60 years, IQR 50-68 vs. 48 years, 33-56; p < 0.01). Extent of ESBS was not associated with readmission or discharge from the ED. The most common discharge diagnoses were headache (n = 13, 24.1%) and epistaxis (n = 10, 18.5%); the most common readmitting diagnoses were serum abnormality (n = 15, 30.0%) and altered mental status (n = 5, 10.0%). Readmitted patients underwent significantly more laboratory testing than discharged patients (median 6, IQR 3-9 vs. 4, 1-6; p < 0.01). CONCLUSIONS Approximately half of patients who presented to the ED following ESBS were discharged home but underwent significant workup. Follow-up within 7 days of discharge, risk-stratified endocrine care pathways, and efforts to address the social determinants of health may be considered to optimize postoperative ESBS care.
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Affiliation(s)
- Neal R Godse
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jakub Jarmula
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Troy D Woodard
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Raj Sindwani
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Raskolnikov D, Tzou DT, Ahn J, Bechis SK, Chi T, Sorensen MD, Stoller M, Harper JD. Multi-institutional variation in performance of low dose computerized tomography for the evaluation of suspected nephrolithiasis. J Endourol 2022; 36:1377-1381. [PMID: 35652350 DOI: 10.1089/end.2022.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction and Objective Guidelines from the American Urological Association (AUA) and American College of Radiology (ACR) recommend that patients with suspected nephrolithiasis undergo low dose computerized tomography (LD CT KUB) as opposed to higher dose conventional imaging. We hypothesized that even at institutions with established LD protocols, higher dose imaging is common. Methods We identified four academic medical centers where LD CT KUB protocols were implemented to yield an Effective Dose (EDose) consistent with national guidelines. Fifty consecutive adult patients who underwent CT KUB specifically for the evaluation of nephrolithiasis were retrospectively reviewed at each site. Patient age, sex, BMI, imaging location, and EDose (millisieverts, mSv) were recorded. Results 200 patients with a mean age of 54 years were identified. 46 patients (23%) underwent CT KUB with EDose ≤ 4 mSv, accounting for 10-48% of each institution's cohort. 116 patients had a BMI < 30, and would have been expected to receive LD CTs by the AUA criteria for LD CT KUB. Within this subset, only 37 patients (32%) actually underwent LD CT KUB. The highest dose CT KUB at each institution resulted in EDose of 33.8-44.6 mSv, exceeding the recommended exposure of LD CT KUB by tenfold. Conclusions At academic institutions where LD CT KUB was implemented for the evaluation of nephrolithiasis, a minority of patients with BMI < 30 receive guideline-concordant imaging. Differences in patient BMI did not account for the variation in radiation exposure. Further research is necessary to elucidate barriers to low dose CT implementation.
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Affiliation(s)
- Dima Raskolnikov
- University of Washington School of Medicine, 12353, Department of Urology, 1959 NE Pacific St, Box 356510, Seattle, Washington, United States, 98195-6340;
| | - David T Tzou
- University of Arizona, Urology, 1501 N. Campbell Ave, PO Box 245077, Tucson, Arizona, United States, 85724;
| | - Justin Ahn
- University of California San Francisco, Urology, San Francisco, California, United States;
| | - Seth K Bechis
- University of California San Diego Health System, 21814, Urology, San Diego, California, United States;
| | - Thomas Chi
- University of California San Francisco, Urology, 400 Parnassus Ave, 6th floor Urology Clinics A638, San Francisco, California, United States, 94143;
| | - Mathew D Sorensen
- University of Washington, Department of Urology, 1959 NE Pacific Street, Box 356510, Seattle, Washington, United States, 98195;
| | - Marshall Stoller
- University of California San Francisco, Urology, San Francisco, California, United States;
| | - Jonathan D Harper
- University of Washington, Department of Urology, Seattle, Washington, United States;
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