Decreasing hospital stay increases post-discharge complications for surgical patients


The results of a new study suggest that the national trend of decreasing hospital stays after surgery may come at the expense of an increasing proportion of complications occurring after patients leave the hospital. The results of one of the few studies exploring the relationship between length of stay (LOS) and post-discharge complications for surgical patients were presented at the American College of Surgeons (ACS) Virtual Clinical Congress 2021.

Hospitals have shortened hospital stays of inpatients over the past two decades due to factors such as a focus on outpatient treatment, lack of beds, cost-cutting measures and payers’ demands. . The new study found that the median, or mean, LOS after surgery fell by a third, from three days in 2014 to two days in 2019.

Although the researchers found that the overall rate of postoperative complications decreased by 1% over the five-year study, they found a 12% increase in post-discharge complications in several common surgical specialties for more than 538 000 American patients.

Multiple serious complications, including infections and heart problems, had significantly higher occurrence rates after discharge in 2019, when the average hospital stay was shorter than in 2014, the co-investigator said. from the Ruojia study Debbie Li, MD, MS. Dr Li is a researcher at Northwestern University Feinberg School of Medicine in Chicago, where the study took place.

There is a black hole that needs to be filled between the time the patient is discharged from the hospital and their first postoperative visit. Currently, we use a waiting model where, as healthcare providers, we wait for surgical patients to approach us with worrying signs and symptoms. “

Ruojia Debbie Li, MD, MS, researcher, Northwestern University Feinberg School of Medicine, Chicago

Patients may not recognize complications

One shortcoming that emerges from this approach is that patients and their family caregivers often fail to recognize the first symptoms of complications, and their problems can then worsen, according to study principal investigator Ryan P. Merkow, MD. , MS, FACS, assistant professor of surgery at Northwestern Medicine, said.

“I have found that many patients and their families are unprepared for the transition from hospital to home and for the task of self-care,” said Dr Merkow. “The surgical team may not discover a complication until the patient goes to the emergency room or comes for a visit to the clinic. If we had known earlier, we could have intervened and reduced the severity of the complication. or even maybe prevent it. “

Dr Merkow said researchers typically count the rate of total complications in the first month after surgery. This number combines complications that occurred in hospital and after discharge. Therefore, there is little evidence on the effect of a shorter hospital stay on post-discharge complications, he said.

Post-discharge complications are on the rise

The research team investigated the association between length of stay and post-discharge complications using the ACS National Surgical Quality Improvement Program (NSQIP®) database. The NSQIP is the leading nationally validated, risk-adjusted, results-based program to measure and improve the quality of surgical care in hospitals and aims to reduce preventable postoperative complications.

Specifically, the researchers evaluated data from 2014 to 2019 for patients who underwent any of 11 colon and rectal surgeries; esophagus; hepatopancreatobiliary system involving the liver, pancreas, gallbladder and bile ducts; or gynecological or urological systems.

Any adverse event occurring after the day of discharge but within 30 days of surgery was considered a post-discharge complication, Dr Li explained. Researchers found that the proportion of post-discharge complications increased from 44, 6% in 2014 to 56.5% five years later.

Complications with significantly higher rates over time, according to Dr. Li, included infections of the surgical site and other infections such as pneumonia, urinary tract infections or infections of the blood known as sepsis. . Other complications that increased as life shortened were heart attack, cardiac arrest or stroke, and a severe blood clot called venous thromboembolism. Many of these complications are potentially preventable; for example, early detection and management of superficial wound infection could prevent consequences such as surgical wound opening and / or sepsis.

Risk factors that were associated with a higher likelihood of complications after discharge included

  • Patient factors: Hispanic or “other ethnicity / race”; higher body mass index; upper class of the American Society of Anesthesiologists (a surrogate for general health used to predict operative risk); loss of independent function; higher wound class (a more serious wound); and experience a complication of hospitalization
  • Intervention factors: a longer operation and the type of surgical intervention

Recommendations

“It is essential not to ignore this important period after the patient is discharged from the hospital,” said Dr Li.

To reduce the rate of complications after discharge, every hospital must have a coordinated system to better identify and manage these complications, said Dr Merkow. He recommended that such a system include the following components:

  • Education of patients and their families before the operation and before discharge, to equip them to recognize the signs and symptoms concerning which they should discuss with their surgeon
  • Easy communication between patient and surgical team
  • Close and more intensive monitoring for patients at high risk of complications

Dr. Li and Dr. Merkow’s Northwestern University research colleagues were Hae Soo (“Rachel”) D. Joung, MD; Jeanette D. Chung, PhD; and Karl Y. Bilimoria, MD, FACS.

Source:

American College of Surgeons


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