Background Unplanned postoperative hospital readmission within 30 days is a major quality improvement focus in medicine, including in neurosurgery and otolaryngology. Recently, postoperative emergency department (ER) use has also become a quality metric that is under-studied to date in neurosurgery. Patients undergoing endoscopic endonasal or microscopic endonasal operations for skull base pathology have unique postoperative considerations for endocrinological abnormalities, epistaxis, cerebrospinal fluid leakage, and meningitis, among others. We investigated the reasons these patients return to the hospital ER after surgery, to develop paradigms for utilization reduction and patient care improvement.
Methods Single-center ethics-board–approved review of all endonasal microscopic or endoscopic procedures performed sequentially for all pathologies (pituitary/sellar and expanded endonasal) at our institution between June 2013 and June 2016.
Results We identified 71 ER visitations after 559 sequential endonasal (295 endoscopic, 264 microscopic) operations during the 3-year study period, yielding a 30-day postoperative ER utilization incidence of 12.7%. The average time to ER presentation after index hospitalization discharge was 8.8 days. Twenty-four of the 71 patients (35%) who utilized the ER presented with hyponatremia (<135 mEq/L), 2 (2.8%) presented with hypernatremia (>145 mEq/L), and 13 (18%) presented with any severity of epistaxis (3 of 13 requiring return to OR for hemostasis). Two patients presented to the ER with delayed CSF rhinorrhea, but none presented with bacterial meningitis. Overall, 30 patients (42% of ER visits) were readmitted to the hospital after presentation to the ER (18% ICU, 24% ward admission) and 5 patients underwent additional surgery during the second hospitalization. Variables from the index hospitalization associated with an increased risk of subsequent postoperative ER utilization included discharge on oral corticosteroids (OR: 3.21, p < 0.0001), either need for postoperative fluid restriction due to SIADH (OR: 2.39, p = 0.008) or postoperative fluctuation of serum sodium greater than 10 mEq/L (OR: 1.81, p = 0.014), intraoperative or postoperative placement of a lumbar drain (OR: 1.75, p = 0.044), and intraoperative CSF leak (OR 1.59, p = 0.017). However, there were no significant differences between patients who returned to the ER within 30 days of surgery and those who did not when comparing age, gender, prior surgery, baseline medical comorbidities, index hospitalization DVT, length of stay, length of surgery, neurological deficit, use of endoscopic versus microscopic surgical approach, percentage of functional versus nonfunctional adenomas, percentage of nonadenoma pathology (e.g., craniopharyngioma, meningioma, others), or need for DDAVP at the time of discharge. Severity of illness (SOI) and risk of mortality (ROM) standardized metrics also did not correlate with postoperative return to the ER.
Discussion This study provides baseline data on ER utilization and hospital readmissions after endonasal skull base surgery, to develop pathways to appropriately triage patients and reduce unnecessary ER visits and subsequent perioperative inpatient readmissions. We propose that a subset of patients at high risk for ER utilization undergo more intensive outpatient management by a multidisciplinary team of neurosurgeons, otolaryngologists, and endocrinologists to reduce ER use and possible hospital readmission.
