Silva Nicole A, Taylor Blake E S, Herendeen John S, Reddy Renuka, Eloy Jean Anderson, Liu James K
Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Ophthalmology and Visual Sciences, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
World Neurosurg. 2019 Apr;124:e131-e138. doi: 10.1016/j.wneu.2018.12.039. Epub 2018 Dec 20.
Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population.
We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program.
Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia.
Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.
尽管降低30天内医院再入院率目前是神经外科质量改进的重点，但术后急诊室就诊情况仍未得到充分了解，尤其是在门诊医疗服务可及性有限的人群中。在内镜经蝶窦手术后，所治疗的独特病理实体可引发多种手术和代谢并发症——这些并发症在表现上往往具有危险性、延迟性且不具有特异性。我们试图在社会经济条件不利的人群中，对急诊室就诊（无论是否再入院）的原因和时间进行特征描述。
我们回顾了2009年至2017年由我们的颅底团队进行内镜经蝶窦手术的所有患者，以确定他们的社会经济状况和急诊室就诊原因。为了进行外部验证，我们将我们的结果与美国外科医师学会国家外科质量改进计划的全国数据进行了比较。
在229名患者中，35名（15.3%）在出院后30天内去过急诊室。在这229名患者中，21名（9.2%）被再次入院，109名（47.6%）由医疗补助计划承保。急诊室就诊的最常见原因是头痛（35例中的8例[22.9%]）、低钠血症（35例中的7例[20.0%]）和鼻出血（35例中的5例[14.3%]）。再次入院的最常见原因是有症状的低钠血症（21例中的6例[28.6%]）。再次入院的其他原因包括脑膜炎（21例中的2例[9.5%]）、肾上腺危象（21例中的2例[9.5%]）和脑脊液漏（21例中的1例[4.8%]）。再次入院的平均时间为10.9天。根据国家外科质量改进计划数据库，30天再入院率为5.5%，其中22.2%是由于低钠血症。
延迟性低钠血症在急诊室就诊和非计划再入院中占很大比例。通过勤奋的多学科护理进行密切随访可能会减少该人群的急诊室就诊次数和再入院率。
