Spine surgery patients experience hospital readmissions for a variety of reasons: Surgical complications, nausea and vomiting, infections and pain management issues to name a few. Urinary retention and wound management also brings patients back to the emergency room a few days after surgery.
"Patient readmissions are exhausting for the families," says Jeffrey Carlson, MD, president of Orthopaedic and Spine Center in Newport News, Va. "The patients go through surgery for a specific problem and the surgeon fixes that problem, but then a new issue arises. That’s stressful and puts patients behind in their rehab. Other times they’re waiting on services for their issues and the patients become stressed about that. They’re expecting things to get better after surgery and that doesn’t happen."
Prevention strategies
There are a few strategies surgeons can take to prevent readmissions when possible, including:
1. Discussing a thorough patient history to identify pain medication use and past urinary retention issues.
2. Speak to family members about whether the patient had a bad reaction to medication or certain anesthetics in the past.
3. Educate the patient about normal postsurgical expectations, including normal pain levels and unpleasant non-life threatening symptoms to avoid emergency room visits.
4. Identify prostate enlargement and other issues that would increase the risk of post-surgical complications.
5. Teach patients and their caretakers to identify early triggers for bigger problems such as UTIs, so they can seek additional treatment early before the issues become full-blown complications. Share with patients what to contact the surgeon about as well.
"You can prevent a lot of problems by talking to the patient beforehand," says Dr. Carlson. "Bringing in family members can also be important in discussing previous surgery and the patient’s current pain meds to prevent readmissions in the future."
Wound care is another important area surgeons can control. "Try to ensure you have the bleeding dried before the patient leaves the OR and make sure the old blood isn’t leaking or the hematoma isn’t leaking out. Be meticulous in the closing of the wound and make sure there isn’t any blood left behind. Sometimes using a drain is helpful if it isn’t completely dry. Larger patients will deeper wounds that may collect surgical fluids, so extra time or drains may be needed."
Building rapport
Surgeons can also learn more about the patient’s attitude going into surgery. Some patients have post-traumatic stress disorder from combat situations or other life experiences and those patients may wake up from surgery needing additional support. Setting expectations for the patient’s post-surgical experience and then individualizing care plans can make a big difference.
"Make sure the patient and family are aware they’ll still be in pain after they’re sent home," says Dr. Carlson. "Spine surgery isn’t a magic wand and the pain won’t just go away. The incisions can also cause pain or pain related to muscle spasms. The pain should be managed enough to allow the patient to participate in therapy and sleep comfortably."
However, if this is the patient’s first major surgery, some complications aren’t identifiable or preventable beforehand. The medical team doesn’t know how the patient will react to anesthesia; in that case, it’s important to work with good anesthesiologists focused on making the patient comfortable and monitoring them while eating and drinking before the patient leaves the hospital or surgery center.
"By having a rapport with the patients and being on board with expectations, surgeons offices, nurses and extenders involved in the care can make sure the patient is on track to return home and won’t be readmitted to the hospital," says Dr. Carlson. "Follow up with the patients at home and check up on their progress in physical therapy and wound management. Make sure they can contact your office to address any issues before heading back to the hospital to prevent the readmission if possible."
Keeping patients out of the hospital if they don’t need hospital care has several benefits:
1. The patient isn’t exposed to additional bacteria, viruses and disease on the return trip to the hospital.
2. The patient’s and hospital’s time is saved by resolving the issue at home instead of clogging the ER with non-emergent issues.
3. It saves the patient and healthcare system money.
"Costs are always increased when patients return to the hospital," says Dr. Carlson. "When you go through the emergency room, the cost for care goes up. This becomes an even bigger issue as surgeons and hospitals take on more risk for the quality of care, accepting a single payment for a 90-day episode of care regardless of additional costs. Surgeons aren’t paid more when their patients are readmitted to the hospital, but it is more work for them."
Surgeon reputation
The surgeon’s reputation also depends on providing good quality care with few readmissions. Patient satisfaction and experience are graded on websites as well as in national surveys to determine the quality, and sometimes payment, of care.
"A good local reputation puts pressure on other physicians in the area," says Dr. Carlson. "The nurses also know which surgeons have good bedside manner and better outcomes. They can spread the word about who is good and who isn’t."
Dr. Carlson’s office goes a step further beyond just patient care to make the experience special. Each surgical patient receives a flower after their procedure and contact information for his office.
"This makes the patients and families know you care about the whole patient. They patients may have been seeing their surgeon for years, but their families don’t always attend all the visits or see your relationship with them. Letting the patient and family know you are concerned makes them feel less reluctant to call about their problems or frustrations before they take the patient back to the hospital," says Dr. Carlson. "If we help to give them the right expectations, we can decrease readmissions."
There is also a push on the national level to prevent readmissions, which is a double-edged sword. While certain guidelines or initiatives may help surgeons identify problems and provide better care, incentivizing surgeons not to readmit patients who might need it is disastrous.
"There is a trend to say physicians with higher readmission rates are worse physicians and surgeons, but there are some surgeons who are more cautious than others in treating older patients who are not doing well at home, and those patients need to return to the hospital," says Dr. Carlson. "It’s a problem not to readmit them if they need it, but there are some who might hesitate just because they don’t want to be listed on a website condemning them for having a higher readmission rate. That hurts patient care."