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Early Discharge: The Rise in Return to the Emergency Department after Surgery

June 11, 2021 | Article No. 56

Early Discharge: The Rise in Return to the Emergency Department after Surgery

June 11, 2021 | Article No. 85

Contributors

Ayesha Siddiqua MSc, PhD

Mohit Bhandari MD, PhD

Dr. Ravi is an orthopaedic surgeon and assistant professor at the University of Toronto. He has a subspecialty practice in total joint arthroplasty. His research is primarily focused on improved outcomes for patients who have undergone total joint replacement and or other orthopaedic procedures.


Insights

-    Emergency department (ED) visits have been on the rise post-discharge for diverse surgical procedures. 

-    While orthopedic surgery does contribute to considerable amount of ED visits, it is not the leading cause of ED visits among other surgical specialties. 

-    Post-operative pain is one of the top reasons for patients to visit the ED. 

-    Some patients are more likely to visit the ED than others, including those with multiple comorbidities. 

-    Surgery wait time is longer than usual during the COVID-19 pandemic which can worsen prognosis, and delayed surgery in turn can lead to poorer outcomes. 

-    There may be a need for increased ED care during the pandemic given patients’ precarious health state before and after surgery and lack of access to necessary care, however there is lack of empericial data to support this hypothesis. 


“Because readmissions signal an opportunity to improve care and reduce costs related to posthospitalization transitions, they have become a hospital quality indicator and policy focus. However, less attention has been paid to events that occur in the immediate postdischarge period that may be markers for poor care coordination. Specifically, the role of the emergency department (ED) in the immediate postdischarge period has received little scrutiny, despite its functioning as the primary source for unscheduled hospitalizations.”
 

Kocher et al. (2013) (1)

“In Canada and the United States (US), the rate of return to ED or hospital admission between 24 h and 14 days after ambulatory surgery ranges from 3.1 to 6.5%. The rate of return to hospital within 30 days after surgery ranges from 3 to 10.5% and varies by surgical procedure.”

Sawhney et al. (2020) (2)

“The number of patients with osteoarthritis who had elective orthopedic surgery ranged from 22700 (246 per 100,000 population) in 2004 to 41900 (381 per 100,000 population) in 2016 (in Ontario). Thirty-day hospital readmissions slightly declined over time (p-value for trend <0.0001): changing from 3.7% in 2004 to 2.9% in 2016, while ED visits increased steadily over the same time period, from 11.1% in 2004 to 15.5% in 2016 (p-value for trend <0.0001).”

Canizares et al. (2019) (3)

“Patients discharged after nonelective (i.e., semiurgent, urgent or emergent) surgeries are at substantial risk of hospital readmissions, presentation to emergency departments or urgent care centres, or death in the 30 days following discharge” 

PVC-RAM

investigators (4)
 

The discharge of patients from hospitals after surgery is a complex process. It signifies the beginning of a vulnerable period of time that is often characterized by many challenges. Without a comprehensive plan to ease the transition of the patient to the community post discharge, there is a greater risk for health complications as well as increase in healthcare utilization. Given the rising strain on the healthcare system – particularly in the context of COVID-19 – many strategies to save costs and improve efficiency have been increasingly implemented to reduce the burden on limited operating budgets, overwhelmed medical facilities, and clinicians who are already spread thin in their capacity to serve patients. One of these strategies that have been implemented across many settings is discharging patients earlier than usual after hospital admissions for a wide range of reasons – including surgery. In the short-term, while this approach to care can in fact reduce costs and allow more patients to receive in-patient care, it can also increase the risk of many post-operative health concerns if patients are not managed properly, which in the long-term can easily undo the short-term benefits of early discharge. In the context of orthopedic surgery, this has some dire implications. Patients who are currently receiving elective orthopedic procedures represent a unique cohort, as many have been waiting to get their surgery longer than usual during the pandemic. During this prolonged wait, the deterioration of their condition is inevitable as even though surgical procedures have been halted in response to the pandemic – the prognosis of different conditions has not. While it may be tempting to discharge these patients early, there is a possibility that they may end up in the emergency department (ED) shortly after if they do not receive the right post-operative care. Post-operative ED visits have been on the rise over the years and identifying the reasons why patients make these visits after surgery, as well as patients who are more likely to make these visits is necessary for optimal healthcare planning that will not only improve patient outcomes, but also contribute to cost-savings and increased efficiency for the healthcare system.  


“Treatment-related complications and symptoms may develop over the hours or days after discharge and require subsequent visits to emergency departments or hospital admissions, termed hospital-based, acute care.”

Fox et al. (2014) (5)

“Acute pain (19.7%) and haemorrhage (14.2%) were the most frequent reasons for an ED visit and “convalescence following surgery” (49.2%) followed by acute pain (6.2%) and haemorrhage (4.5%) were the main reasons for admission (among patients who had ambulatory surgery).”

Sawhney et al. (2020) (2)

“Most common reasons for ED visits were for pain (31.5%), bleeding (17.6%), and infection (14.8%) (among patients who had head and neck surgery).”

Wu & Hall (2018) (6)

“Current arthroplasty literature examining causes of ED visits after hip and knee arthroplasty indicates there is a high incidence of potentially unnecessary ED visits, noting 90% of patients were sent home from the ED and did not require admission.”

Sivadundaram et al. (2020) (7)

Why do patients visit the emergency department after surgery?

According to the Canadian Institute of Health Information (CIHI), post-surgical related issues are among the top 10 most common reasons for ED visits for individuals aged 18 to >85 years, which accounts for 5-11% of potentially avoidable ED visits (8). Evidence from the U.S. shows that across different surgical procedures, cardiovascular and respiratory diagnoses were common reasons for ED visits, but there is also significant variability in the reasons for visit depending on the procedure itself (1). Importantly, reasons that led to ED visits with readmission compared to ED visits with discharge were often different for the same procedure (1). For example, for hip fracture repair, the top 3 reasons for ED visits with readmission were cardiovascular or respiratory (25.8%), infection (17.9%), and generalized symptoms (11.7%); whereas the top 3 reasons for ED visits with discharge were injury related (22.5%), skin or non-injury-related musculoskeletal (17.8%), and generalized symptoms (13.8%) (1). Recent evidence from Canada shows that after total joint arthroplasty, the rate of ED visit was high, even though most of the patients could have been managed in out-patient settings – where majority of concerns were family practice sensitive conditions (9). This highlights a missed opportunity to improve patient education so they are better informed regarding their post-operative sequelae and prepared to seek care from the appropriate settings – thereby reduce unnecessary healthcare costs at the ED (9). 



It has been widely emphasized that with the shift in care model moving from surgeries followed by protracted postoperative hospital stays to more short stay and ambulatory surgeries have been one of the contributing factors for the rise in ED visits (10). When patients had longer hospital stays, surgeons were more closely involved in identifying and treating postoperative complications and ensuring that continuity of care was maintained (10). It has been found that the most common reasons for hospital-based acute care after ambulatory surgery are procedure-related complications, as well as post-surgery pain and discomfort (5). There is evidence indicating that majority of these acute care encounters occur as ED visits that do not need subsequent hospital admission, although they do occur outside normal office hours (5). 


“Patients who had undergone coronary artery bypass grafting had the highest ED use, at 22.4 percent, while those who had undergone back surgery had the lowest ED use, at 12.2 percent. A small but substantial portion of patients had multiple ED visits (4.4 percent) within this thirty-day time frame. Most readmissions after the six procedures examined occurred through the ED (56.5 percent).”

Kocher et al. (2013) (1)

“Those with Medicare and Medicaid insurance are more likely present to the ED after arthroplasty and foot and ankle surgery…the increased ED utilization by this cohort is likely attributable to a higher number of barriers to care, including trouble accessing providers and the absence of transportation to outpatient clinics.”

Sivasundaram et al. (2020) (7)

Who is more likely to visit the emergency department?

There has been significant research examining factors associated with increased likelihood of ED visits among patients who had surgery. These factors span different levels of influence, starting from the patient then hierarchically moving up to the health system. Exhibit 1 summarizes findings of several recent studies that have examined these diverse factors in relation to ED visits. Nonetheless, the complexity of identifying predictors for ED visits is demonstrated by the findings of a recent population based study from Canada that utilized administrative data (9). Even though the predictive models in this study identified many of the commonly reported risk factors for ED visits, these models were only slightly better than chance with their predictions – which has been attributed to the missing data regarding factors related to post-operative care in the community as well as the heterogeneity of patients (9).  



Notably, among the few epidemiological studies that are available in this area, there is documented variation in the surgical procedures leading to the most ED visits post-discharge. Even though orthopedic surgeries are typically not the leading cause of ED visits when different specialties of surgeries are considered, there is evidence suggesting they do in fact contribute to a significant proportion of these visits – as found across several studies (1,2).  


Exhibit 1: Factors increasing likelihood of ED visits after surgery (3,7,11)


Patient Sex (male)
Older age 
Living in rural areas 
Presence of comorbities 
Increased comorbidity 
Development of complications 
Health system Short length of stay and discharged home (with or without support)
Medicare insurance 
Medicaid insurance

In the U.S., Medicare is a federal program that provides health coverage to those 65+ or under 65 and have a disability, regardless of their income. Medicaid is a state and federal program that provides health coverage to those with a very low income. If someone is eligible for both Medicare and Medicaid (dually eligible), they can have both insurance coverage. 


“As early as 2002, a retrospective cohort study found that the timing of total joint arthroplasty might impact clinical outcomes among patients with osteoarthritis of the hip or knee: patients receiving operations in the earlier course of functional decline had better outcomes (Fortin et al., 2002). An empirical study published in 2007 identified that increasing waiting time was associated with poor postoperative outcomes, such as deterioration measured by the total scale of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) (Kapstad et al., 2007).”

OE Original: Resuming Elective Surgeries During COVID-19: Déjà vu 1 Year Later

“One-fifth of patients awaiting total hip arthroplasty and 12% of patients awaiting total knee arthroplasty are defined as in a health state ‘worse than death’ by the EuroQol five-dimension (EQ-5D) score.”

Scott et al. (2019) (12)

“We know that many physicians are striking the right balance, but unfortunately we’re increasingly hearing about physicians’ offices that are not providing in-person care, emergency departments that are seeing patients who would be better managed in other settings, an increase in later-stage cancer diagnoses, and referrals to specialists being made without appropriate physical examinations that would have altered the need for a referral if they were done.”

College of Physicians and Surgeons of Ontario (2021) (13)

Emergency department visits post surgery in the time of COVID-19

Recognizing that some patients are more likely to have ED visits than others, particularly in terms of their clinical characteristics, we can begin to appreciate why ED visits post-surgery during the pandemic may be different than the trends observed pre-pandemic. In our previous OE Insights, we have provided extensive details regarding the surgery backlog that has been accumulated as a result of postposing elective surgery with no definitive future date for pending procedures in sight. Our OE models earlier in the pandemic predicted a 3.4 fold increase in surgical wait-times (given a 12-month recovery to 90% of pre-pandemic capacity), however, recent models based on real-world data show a 153-fold increase in length in waitlists. During this prolonged wait time, the patient’s condition can deteriorate significantly – thus, by the time they receive their surgery, they are likely to be in a far more compromised health state than they would have been at the time of a surgery performed earlier without delay. In our previous OE Original, we have highlighted the clinical consequences of waiting for surgery. In the context of orthopedic surgery, there is evidence indicating that waiting for surgery is associated with poorer post-operative outcomes. Thus, not only are patients more likely to enter the operating room in a worse than usual health state compared to the pre-pandemic era, but they are also at greater risk of having poorer outcomes post-surgery. This has profound implications for their health care use. They may be more likely to seek health care given their poor health state after discharge – specifically, they may be more likely to visit the ED since primary care has adopted a virtual delivery model during the pandemic, which may not be appropriate for many post-operative concerns. To our knowledge, there is no empericial evidence so far to support this hypothesis. Furthermore, CIHI found that earlier in the pandemic, by the end of April 2020, ED visits in Canada fell by nearly half (14). Similar trends were also observed in the U.S. from January to April 2020 (15). As elective surgeries are increasingly resumed across different settings, it will be important to track whether there has been an increase in ED visits post-surgery, as suggested by anecdotal data, and the reasons for these visits in order to develop the necessary health care delivery plan accordingly. At a broader level, there is evidence from Canada showing that there has been an increase in ED visits following total knee arthroplasty between 2003 and 2016, with a downward trend towards shorter length of stay (15). Considering that challenges associated with COVID-19 are manifesting within preexisting systems that have led to an increase in ED visits, we feel our hypothesis regarding increase in ED visits as elective surgeries are resumed is a plausible one. 


“Presentation to an ED is common even after elective surgeries and some of these unplanned visits can be preventable with good postsurgical as well as physician-patient coordination.”

Shibuya et al. (2018) (17)

“An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters (among those with colorectal surgery).”

Lumpkin et al. (2020) (18)

“It is important to note, however, that there is likely a baseline unmodifiable expected rate of ED visits in the period immediately following a hospitalization, with the sickest patients requiring stabilization through further hospitalization. For example, in postsurgical patients, such as those considered in our study, there are known delayed surgical complications, including wound infections, that may not be avoidable—particularly after nonelective procedures—and that could precipitate a downstream ED visit. Therefore, any application of the postdischarge ED visit as a hospital quality measure should reflect a nuanced understanding of the dynamics underlying these visits.”

Kocher et al. (2013) (1)

Strategies to reduce emergency department visits

“A strong rationale and encouraging evidence suggest that virtual care with remote automated monitoring (RAM) will increase the number of days alive at home, in adults discharged after surge

Yang et al. (2018) (19)

Notwithstanding that some ED visits can not be avoided, there are many instances where these visits can indeed be prevented with proactive planning. In the past, there have been calls for greater investment and coordination to facilitate continued care delivery to reduce the burden on the ED, including the following (2,20): 



-    Overall improved discharge planning 

-    Enhancing access to appropriate outpatient care 

-    Providing earlier follow up as needed 

-    Customized pain management strategy 

-    Improved home care 

-    Post-operative nursing support by telephone 

-    Improved maintenance of communication between the patient and the treatment team after discharge through diverse means 

-    Improved patient education 



Recent innovations include the use of remote access monitoring of patients (4).  Mike McGillion notes that “we can increase our capacity to do more elective and urgent surgeries, if we can reduce the volume of hospital admissions. Especially since patients transition home sooner after surgery, globally remote patient monitoring is going to be the way of the future.” Large randomized trials are ongoing to evaluate the impact of this innovative approach on patient outcomes following surgical discharge from hospital.  



Additionally, it has been noted that factors that have been shown to influence hospital readmission rates can also show similar impact for ED vitsits. This includes more intensive outpatient management and better overall care coordination (1). It has been also suggested that factors that impact ED visits can even begin at the time of surgery from the health service perspective, including the quality of perioperative care prior to the patient being released from the hospital (1). In light of the COVID-19 pandemic, it is now more important than ever to improve the transition of care from in-patient to out-patient settings to not only improve patient outcomes, but also reduce burden on a healthcare system that has already reached a tipping point in its capacity to provide quality care to those in need. 


Contributors

Ayesha Siddiqua MSc, PhD

Ayesha Siddiqua completed her graduate training from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University. She is a Data Scientist at OrthoEvidence.

Mohit Bhandari MD, PhD

Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.

References

1.    Kocher KE et al (2013). Emergency department visits after surgery are common for Medicare patients, suggesting opportunities to improve care. Health Affairs (Project Hope); 32(9): 1600-7. DOI: 10.1377/hlthaff.2013.0067 
2.    Sawhney M et al (2020). Pain and haemorrhage are the most common reasons for emergency department use and hospital admission in adults following ambulatory surgery: results of a population-based cohort study. Perioperative Medicine, 25.  
3.    Canizares M et al (2019). Unplanned readmissions and emergency department visits following orthopedic surgery for osteoarthritis from 2004 to 2016 in Ontario, Canada: The impact of the changing profiles of patients and clinical care. Osteoarthritis and Cartilage; 27(S34). DOI: 10.1016/j.joca.2019.02.050 
4.    McGillion MH et al (2021). Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM): protocol for a randomized controlled trial. CMAJ Open; 9(1): E142-E148. DOI: 10.9778/cmajo.20200176
5.    Fox JP et al (2014). Hospital-based, acute care after ambulatory surgery center discharge. Surgery; 155(5): 743-753. DOI: 10.1016/j.surg.2013.12.008
6.    Wu V & Hall SF (2018). Rates and causes of 30-day readmission and emergency room utilization following head and neck surgery. Journal of Otolaryngology - Head & Neck Surgery; 36. 
7.    Sivasundaram L et al (2020). Emergency department utilization after outpatient hand surgery. Journal of the American Academy of Orthopaedic Surgeons; 28(15): 639-649. 
8.    Canadian Institute for Health Information (2014). Sources of Potentially Avoidable Emergency Department Visits. Retrieved from https://secure.cihi.ca/free_products/ED_Report_ForWeb_EN_Final.pdf 
9.    Ravi et al. (2020). Factors associated with emergency department presentation after total joint arthroplasty: a population-based retrospective cohort study. CMAJ Open; 8(1):E26-E33. DOI: 10.9778/cmajo.20190116 
10.    Sugar R et al (2018). The Red Dot Initiative: An analysis of postoperative visits to the emergency. BC Medical Journal; 60(8): 398-402. 
11.    Chaudhary MA et al (2018). Does orthopaedic outpatient care reduce emergency department utilization after total joint arthroplasty? Clinical Orthopaedics and Related Research; 476(8): 1655-1662. DOI: 10.1097/01.blo.0000533620.66105.ef 
12.    Scott CEH et al (2019). 'Worse than death' and waiting for a joint arthroplasty. The Bone & Joint Journal; 101-B(8):941-950. DOI: 10.1302/0301-620X.101B8.BJJ-2019-0116.R1
13.    College of Physicians and Surgeons of Ontario (2021). COVID-19 FAQs for physicians. Retrieved from https://www.cpso.on.ca/Physicians/Your-Practice/Physician-Advisory-Services/COVID-19-FAQs-for-Physicians
14.    Ho S (2021). Don't avoid going to the ER because of pandemic, Canadians urged. Retrieved from https://www.ctvnews.ca/health/don-t-avoid-going-to-the-er-because-of-pandemic-canadians-urged-1.5268577?cache=nkwcgcjqfzosqu%3FclipId%3D104069 
15.    Jeffery MM et al (2020). Trends in emergency department visits and hospital admissions in health care systems in 5 states in the first months of the COVID-19 pandemic in the US. JAMA Internal Medicine; 180(10): 1328-1333. DOI: 10.1001/jamainternmed.2020.3288
16.    Ross et al (2020). Temporal trends and predictors of thirty-day readmissions and emergency department visits following total knee arthroplasty in Ontario Between 2003 and 2016. The Journal of Arthroplasty; 35(2):364-370. DOI: 10.1016/j.arth.2019.09.015
17.    Shibuya N et al. (2018). Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries. Proc (Bayl Univ Med Cent); 31(2):157–160. DOI: 10.1080/08998280.2018.1441251
18.    Lumpkin ST et al (2020). Early Follow-up After Colorectal Surgery Reduces Postdischarge Emergency Department Visits. Diseases of the Colon and Rectum; 63(11): 1550-1558. DOI: 10.1097/DCR.0000000000001732
19.    Yang et al. (2018). Postoperative home monitoring after joint replacement: Retrospective outcome study comparing cases with matched historical controls. JMIR Perioperative Medicine; 1(2):e10169. DOI: 10.2196/10169
20.    Cancer Quality Council of Ontario (2020). Unplanned Hospital Visits and Readmission After Surgery. Retrieved from https://www.csqi.on.ca/en/2020/indicators/unplanned-hospital-visits-after-surgery

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