Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Neurosurgery. 2018 Jan 1;82(1):110-117. doi: 10.1093/neuros/nyx151.
After transsphenoidal surgery, delayed hyponatremia (DH) is the leading cause of 30-d unplanned hospital readmissions.
To determine the impact of a DH care pathway on 30-d readmissions after transsphenoidal surgery.
Data from before and after DH care pathway implementation were retrospectively reviewed. Patient demographics and clinical characteristics were compared. Readmission causes, clinical pathway failures, sodium trends, and symptoms were evaluated.
Before the DH care pathway implementation, 229 (55%) patients were treated (group 1); afterward, 188 (45%) were treated (group 2). Baseline characteristics were equivalent between groups, except for glucocorticoid supplementation, which was higher in group 2. The incidence of detected DH was significantly lower in group 1 (16/229, 7%) than group 2 (29/188, 15%) (P = .006) likely due to the impact of routine screening in group 2. Ten group 1 patients (4%) were readmitted for hyponatremia and 6 (3%) were managed as outpatients. Eleven group 2 patients (6%) were readmitted and 17 (9%) were managed as outpatients. Readmission rates between groups were similar (P = .49). Patients readmitted with severe hyponatremia experienced symptoms ≥24 h before presentation. The protocol failed to prevent readmission because outpatient management for mild or moderate DH (n = 4) failed, sodium levels precipitously declined after normal screening (n = 3), and severe hyponatremia developed after scheduled screenings were missed (n = 3).
Although more DH patients were identified after care pathway implementation, readmission rates were not reduced and clinical outcomes were not changed. Because DH onset timing varies, some patients have highly acute presentation, and most readmitted patients develop symptoms before reaching their sodium nadir, close symptom monitoring may be a reasonable alternative to routine screening.
经蝶窦手术后，迟发性低钠血症（DH）是导致 30 天非计划性住院再入院的主要原因。
确定 DH 护理路径对经蝶窦手术后 30 天再入院的影响。
回顾性分析 DH 护理路径实施前后的数据。比较患者的人口统计学和临床特征。评估再入院原因、临床路径失败、钠趋势和症状。
在 DH 护理路径实施前，229 例（55%）患者接受治疗（组 1）；之后，188 例（45%）接受治疗（组 2）。两组间的基线特征相当，除了组 2 中糖皮质激素的补充更高。组 1 中发现 DH 的发生率明显低于组 2（16/229，7%）比组 2（29/188，15%）（P =.006），这可能是由于组 2 中常规筛查的影响。组 1 的 10 例患者（4%）因低钠血症再入院，6 例（3%）作为门诊患者进行管理。组 2 的 11 例患者（6%）再入院，17 例（9%）作为门诊患者进行管理。两组的再入院率相似（P =.49）。因严重低钠血症而再次入院的患者在就诊前 24 小时以上出现症状。该方案未能防止再入院，因为轻度或中度 DH（n = 4）的门诊管理失败，正常筛查后钠水平急剧下降（n = 3），以及错过了计划的筛查导致严重低钠血症（n = 3）。
尽管护理路径实施后发现更多的 DH 患者，但再入院率并未降低，临床结果也未改变。由于 DH 的发病时间不同，有些患者的表现非常急性，而且大多数再次入院的患者在达到钠最低点之前出现症状，因此密切的症状监测可能是常规筛查的合理替代方法。
