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revisits following same-day surgery: Have they decreased over a decade?
Journal of Clinical Anesthesia 42 (2017) 15
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Pain related readmissions/revisits following same-day surgery: Have they decreased over a decade? Same day surgery (SDS) has become an increasingly common and attractive option for hospitals and patients alike due to its practicality and affordability. Readmission following SDS, however, can affect morbidity, cost, and satisfaction. A study published in this journal from a large hospital system in 2002 revealed that pain was a leading and costly cause of hospital revisits and readmissions following SDS [1]. Improvements in pain care delivery as well as an increased focus on pain quality and cost have occurred over the intervening decade. We designed a retrospective study to examine causes of readmission in our health system over a one-year period, specifically to determine if pain was still a significant factor in revisits and readmissions. Following local IRB approval, admissions and billing data for the 28,647 patients undergoing SDS in 2012 in the Beaumont Health System revealed that 1597 returned to the hospital within a 30-day time period following surgical procedure. Of these, 39.8% were admitted for reasons directly related to the original SDS procedure, and 9.3% overall, and (23.3% of readmissions) were directly related to surgical pain. Records of patients readmitted for surgical pain-related causes were further evaluated to determine what treatment modalities were used for pain management and if patients were expected to be at risk for inadequate pain control. Based on this analysis, further patient categorization is shown in Table 1. Patients who were readmitted for pain but who had none of the listed risk factors were classified as: multimodal analgesia adequate (57 patients), or one or more analgesic medications was used in conjunction with peripheral nerve blockade (25 patients). Overall, 60 of 145 patients (41%) had at least one risk factor for readmission related to pain. Appropriate pain control is a necessary step in providing safe, quality care for surgical patients. We sought to determine if a decade of focus on pain control has improved incidence of readmissions/revisits due to pain following SDS. We found that while the percentage of revisits/ readmits was similar to those described by Coley and colleagues (5.7 versus 5.4), the percentage of readmits related to pain had in fact decreased (by 58%).
Table 1 Categorization of patients at risk for potentially inadequate postoperative pain control. Potential contributing factors to inadequate pain control
Number of patients
Pain medication not given during initial surgical procedure Pain medication given but only as opioid monotherapy Multimodal analgesia used but in inadequate doses Pre-existing chronic pain No analgesic prescriptions given at time of discharge
8 24 6 18 4
http://dx.doi.org/10.1016/j.jclinane.2017.06.009 0952-8180/© 2017 Elsevier Inc. All rights reserved.
Potential reasons for this drop could include differences in patient risk, improvements in screening/prevention, or improvements in pain management techniques. As our secondary analysis revealed, however, some of the pain revisits/readmits were still potentially avoidable. Although generalizations about patients are often ill advised, it seems appropriate to use multimodal analgesics for all patients, with the numbers and types of medications used commensurate with surgical insult. Further, it seems appropriate to discharge patients with pain medications, although we recognize the ongoing controversy of prescribed opioids. Finally, chronic pain patients undergoing surgical procedures require special coordination of care, and discussions of pain management should start as soon as the procedure is scheduled, and should include the surgeon, anesthesiologist, and the patient's own pain specialist. Pain continues to be a significant cause of surgically related readmissions and revisits. In our analysis, nearly half of these readmissions were attributable to inadequate pain management in the peri-operative period, and half of these were potentially avoidable with appropriate care management. A team-wise approach to pain management should be stressed in the SDS patient population, and discharge planning should include specific focus on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment. References [1] Coley K, Williams B, DaPos S, Chen C, Smith R. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. J Clin Anesth 2002;14:349–53.
Martha O. Herbst, MD Matthew D. Price, MD Roy G. Soto, MD* Department of Anesthesiology, Beaumont Health, 3601 West 13-mile Road, Royal Oak, MI 48073, United States ⁎Corresponding author. E-mail address: [email protected] (R.G. Soto). 7 October 2016 Available online xxxx
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Pain related readmissions/revisits following same-day surgery: Have they decreased over a decade? Same day surgery (SDS) has become an increasingly common and attractive option for hospitals and patients alike due to its practicality and affordability. Readmission following SDS, however, can affect morbidity, cost, and satisfaction. A study published in this journal from a large hospital system in 2002 revealed that pain was a leading and costly cause of hospital revisits and readmissions following SDS [1]. Improvements in pain care delivery as well as an increased focus on pain quality and cost have occurred over the intervening decade. We designed a retrospective study to examine causes of readmission in our health system over a one-year period, specifically to determine if pain was still a significant factor in revisits and readmissions. Following local IRB approval, admissions and billing data for the 28,647 patients undergoing SDS in 2012 in the Beaumont Health System revealed that 1597 returned to the hospital within a 30-day time period following surgical procedure. Of these, 39.8% were admitted for reasons directly related to the original SDS procedure, and 9.3% overall, and (23.3% of readmissions) were directly related to surgical pain. Records of patients readmitted for surgical pain-related causes were further evaluated to determine what treatment modalities were used for pain management and if patients were expected to be at risk for inadequate pain control. Based on this analysis, further patient categorization is shown in Table 1. Patients who were readmitted for pain but who had none of the listed risk factors were classified as: multimodal analgesia adequate (57 patients), or one or more analgesic medications was used in conjunction with peripheral nerve blockade (25 patients). Overall, 60 of 145 patients (41%) had at least one risk factor for readmission related to pain. Appropriate pain control is a necessary step in providing safe, quality care for surgical patients. We sought to determine if a decade of focus on pain control has improved incidence of readmissions/revisits due to pain following SDS. We found that while the percentage of revisits/ readmits was similar to those described by Coley and colleagues (5.7 versus 5.4), the percentage of readmits related to pain had in fact decreased (by 58%).
Table 1 Categorization of patients at risk for potentially inadequate postoperative pain control. Potential contributing factors to inadequate pain control
Number of patients
Pain medication not given during initial surgical procedure Pain medication given but only as opioid monotherapy Multimodal analgesia used but in inadequate doses Pre-existing chronic pain No analgesic prescriptions given at time of discharge
8 24 6 18 4
http://dx.doi.org/10.1016/j.jclinane.2017.06.009 0952-8180/© 2017 Elsevier Inc. All rights reserved.
Potential reasons for this drop could include differences in patient risk, improvements in screening/prevention, or improvements in pain management techniques. As our secondary analysis revealed, however, some of the pain revisits/readmits were still potentially avoidable. Although generalizations about patients are often ill advised, it seems appropriate to use multimodal analgesics for all patients, with the numbers and types of medications used commensurate with surgical insult. Further, it seems appropriate to discharge patients with pain medications, although we recognize the ongoing controversy of prescribed opioids. Finally, chronic pain patients undergoing surgical procedures require special coordination of care, and discussions of pain management should start as soon as the procedure is scheduled, and should include the surgeon, anesthesiologist, and the patient's own pain specialist. Pain continues to be a significant cause of surgically related readmissions and revisits. In our analysis, nearly half of these readmissions were attributable to inadequate pain management in the peri-operative period, and half of these were potentially avoidable with appropriate care management. A team-wise approach to pain management should be stressed in the SDS patient population, and discharge planning should include specific focus on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment. References [1] Coley K, Williams B, DaPos S, Chen C, Smith R. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. J Clin Anesth 2002;14:349–53.
Martha O. Herbst, MD Matthew D. Price, MD Roy G. Soto, MD* Department of Anesthesiology, Beaumont Health, 3601 West 13-mile Road, Royal Oak, MI 48073, United States ⁎Corresponding author. E-mail address: [email protected] (R.G. Soto). 7 October 2016 Available online xxxx