Costs for care increase when patients are readmitted to the hospital for any reason, and readmissions are scrutinized more now than ever.
High readmission rates could become lethal to healthcare providers as they strike bundled payment agreements with payers to assume more risk for an episode of care. The Centers for Medicare and Medicaid Services could even penalize providers with high readmission rates in the future.
As a result, surgeons are paying more attention to preoperative patient histories and education as well as postoperative check-ups to prevent readmissions in the future.
"The most common reason for patients returning to the hospital are infections," says Brian Gantwerker, MD, of The Craniospinal Center of Los Angeles. "The patient is either coming back with a superficial wound infection. Most patients don't need to be readmitted, but if the patient has diabetes or doesn't follow wound management instructions and gets a deeper infection, they'll need additional treatment."
Other common complications include pulmonary embolism, cardiac complications, nausea, urinary retention and swallowing issues for cervical procedures. While most patients can recover without many issues, older patients have a harder time and often need a chest CT and swallow study as well as dietary modifications.
"There are some rare complications where patients have esophageal injuries that can be life threatening and that's usually picked up quickly after surgery, but sometimes gets missed if there is patient non-compliance," says Dr. Gantwerker. "That can have a fatality of up to 30 percent. Regardless of the cause, you have to have a low index as a physician for bringing the patient back into the hospital. If there is any reason for concern, you have to have a work-up done."
Dr. Gantwerker's practice includes wound care protocol for patients undergoing minimally invasive procedures as well as patients receiving sutures. Patients with sutures have posterior cervical procedures and Dr. Gantwerker removes the dressing, paints the incision and then dries it. He uses SteriStrip to keep the wound closed and changes the strip one week after surgery.
"I noticed a huge decrease in infections after doing that," says Dr. Gantwerker. "In terms of intraoperative protocol, I use vancomycin powder in posterior cervical and lumbar cases. Wherever there is hardware, I use the powder. But I don't do it with anterior cervicals to keep the powder from compromising the airway."
He also has wound protocol for patients:
1. He is restrictive in letting patients shower and encourages sponge baths until the sutures are out.
2. A nurse practitioner educates patients on dressing changes and gives written protocol.
3. His office follows up with patients to make sure they're following protocol.
In addition to increasing cost, readmissions impact patient satisfaction and experience.
Follow-up visits are crucial, even if they don't translate to highly billable appointments, because they can change the patient's perceptions of care.
"A lot of surgeons see that as a wasted slot in their schedule, and have PAs or NPs following the patient after surgery," says Dr. Gantwerker. "But it only takes eight to 10 minutes for the surgeon to see the patient, and the surgeon can get a better idea if something is wrong or what their outcomes are. This also helps the surgeon remember the patient and develop a closer relationship, and that's rewarding."
The close relationship with patients can smooth things over even if there is a complication and help patients feel better about their recoveries.
"I'm not completely sure readmissions change the outcomes, but the patient's perception is altered. The patient is unsatisfied with a long recovery due to the complication and readmission," says Dr. Gantwerker. "Other times, the patient is happy the surgeon is cautious. Even though it costs more and causes stress, it's the better way to go because if you do catch the complication early there is a shorter length of stay than if you let it fester and become a bigger problem. Perception in outcome is almost as important as the outcome scores because patients will make referrals and online reviews based on their experiences."
There are many initiatives on a local level to curb readmissions and grand ideas about improving patient care through mandates and regulations. But, it's not always possible on the local level to implement a single rule effectively.
On a global scale, there are movements to improve patient care and reduce readmissions through:
1. Judicious use of antibiotics to discourage poly-resistant drug organism growth
2. Partnerships with outpatient home health agencies and wound specialists to make sure patients have a good postoperative experience
3. Using secure emails for patients to send photos of the surgical site to catch issues early
"These initiatives have to come from within the medical professional bodies," says Dr. Gantwerker. "I don't think CMS can successfully mandate a rigid protocol. Professional societies can encourage patients to engage in better postoperative care. We have to come up with something, because if we don't, we'll be dictated how to do it. Once that starts, it's hard to stop. We as surgeons need to take ownership of our patients' care."