Emergency visits and readmissions in an enhanced recovery pathway: Opportunity for quality improvement

Tanya Castelino, MD1, Julio F Fiore Jr., MSc, PhD1, Nicolo Pecorelli, MD1, Patrick Charlebois, MD, FRCSC2, Sender Liberman, MD, FRCSC, FASCRS, FACS2, Barry L Stein, MD, FRCSC, FACS2, Gerald M Fried, MD, FRCSC, FACS1, Liane S Feldman, MD, FRCSC, FACS1. 1Steinberg-Bernstein Centre for Minimally Invasive Surgery, 2Department of Surgery, McGill University Health Centre

Background: Enhanced recovery pathways (ERPs) are associated with shorter length of stay (LOS) after colorectal surgery. There may be concern that early discharge results in higher Emergency Department (ED) visits and readmissions. The aim of this study was to identify risk factors for ED visits and readmissions after bowel resection in an ERP.

Methods: Between September 2012 and May 2014, data from 231 consecutive patients undergoing bowel resection within an established ERP at a University hospital were prospectively collected in a dedicated database. The targeted discharge date in the ERP was 3 days. Patient follow-up, supplemented by medical record review, included post-discharge ED visits, readmissions and complications within 30 days of surgery. Patients with a LOS > 30 days during primary stay were excluded from the analysis. Logistic regression analysis was performed to identify predictors for ED visits and readmissions.

Results: A total of 227 patients were included in the analysis (mean age±SD 62.6 ± 14.8 years, 52% male, 57% cancer, 73% laparoscopy, 39% rectal surgery, 27% new stoma creation). Median length of primary stay was 4 days (IQR 3-7 days). 84 patients (37.0%) were discharged within the targeted LOS. 46 patients (20.3%) had an ED visit and 32 patients (14.1%) were readmitted within 30 days of operation. 30 patients (65%) who had post-discharge ED visits were readmitted. Common presenting issues for ED patients who were not readmitted included wound issues, respiratory symptoms, and urinary retention. The most common causes of readmission were intra-abdominal abscess/anastomotic leak (n=10, 4.4%), ileus/mechanical small bowel obstruction (n=9, 4.0%) and gastrointestinal hemorrhage (n=3, 1.3%). Patients with initial LOS <3 days had similar ED visits (n=15, 18.0%) compared to the LOS>3 group (n=31, 21.7%), p=0.489. Readmission rate was lower, but not statistically significant, in the LOS <3 group (n=8, 9.5% vs. n=24, 16.8%), p=0.129. The only independent predictor of readmission was the creation of a new stoma (OR 1.69, 95% CI 1.15-2.48, p=0.007) while age, gender, ASA, type of surgery, and complications during primary stay were not risk factors for post-discharge ED visits or readmissions.

Conclusions: Within an enhanced recovery program, shorter LOS did not lead to increased readmissions or emergency visits. The formation of a new stoma, perhaps reflecting more complex procedures, was the only independent predictor of readmission. ED visits for minor complications represent a quality improvement opportunity, as many are potentially preventable with better access to outpatient care.

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