Study: Many post-op ER visits preventable

San Francisco-About half of postoperative visits to emergency rooms following urologic surgery could be prevented, but simply improving patient education may not significantly reduce the number of these visits, researchers say.

“What we may think is common sense would have prevented a lot of emergency department visits,” Hari Sawkar, MD, chief urology resident at the University of Southern California (USC) in Los Angeles told Urology Times. He presented the research at the AUA annual meeting in San Francisco.

Few studies describe emergency department visits following urologic surgery, he said. Most of these are after stone surgery, and study designs vary substantially, with researchers reporting rates of emergency department visits from 7% to 15%.

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To characterize emergency department utilization and readmissions, the authors used data from the USC Los Angeles County + USC Medical Center. Located in East Los Angeles, the 600-bed facility has 40,000 discharges and handles 150,000 emergency department visits per year. The patient population is ethnically and linguistically diverse, with many economically disadvantaged.

Dr. Sawkar and his colleagues identified cases of patients returning to the emergency room within 90 days of urologic surgery. They reviewed medical records to determine clinical causes and whether the emergency room visits were preventable. They then designed interventions in an attempt to reduce the number of preventable emergency department visits.

At baseline (July to September 2015), the medical center did 53 urologic procedures per month, of which 20.8% resulted in emergency department visits, with 50.9% of those visits deemed preventable. The mean number of days from surgery to an emergency department visit was 13.9.

The most common reason for an emergency room visit, accounting for 25.8% of the visits, was a question about a wound. Another 16.4% stemmed from a non-wound infection, and 16.1% were for surgical site pain. Drain and catheter issues accounted for another 15.8%, and hematuria for 13.3%.

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Based on their analysis of these causes, the authors found two common problems leading to a preventable emergency department visit. First, the patients couldn’t get access to urology providers to ask questions. Second, they had unclear expectations about recovery from the surgery.

To see if they could address these problems, the authors devised handouts specific to the most common urologic procedures and provided them to patients in English and Spanish. Patients received preoperative calls from nurse practitioners and postoperative calls by operating residents.

The handouts include a description of the procedure. They tell patients how to prepare-for example, by avoiding medications that can increase bleeding. They explain what to expect after surgery, such as pain and hematuria with transurethral resection of a bladder tumor (TURBT).

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The handouts also list symptoms that justify a trip to the emergency room or a 911 call. In the case of TURBT, symptoms listed are: severe pain, uncontrolled vomiting, high fevers, significant bleeding, chest pain, shortness of breath, severe headache, or loss of consciousness.

In the 24 months after introducing the handouts, the authors recorded 1,333 urologic procedures leading to 204 emergency department visits (15.3%), of which 99 (48.53%) were preventable, and 51 readmissions (3.83%). The mean time from the operating room to the emergency department was 12.6 days.

The most common reasons for the emergency department visits after the introduction of the handouts were pain and clogged, leaking, or dislodged Foley catheter, drain, or percutaneous nephrostomy tubes. Both of these accounted for 18%. Another 11% each were for infectious complications and hematuria.

The change in the rate of preventable emergency department visits was not statistically significant, said Dr. Sawkar, who worked on the research with Jeffrey Loh-Doyle, MD, and colleagues. “Even though our intervention didn’t work, we can try new things,” Dr. Sawkar said.

Since collecting these statistics, the medical center has launched a website with procedure-specific information, a comprehensive urology phone tree to reduce the number of calls fielded by front-line staff, and opportunities for patients to contact residents on call after the clinic is closed. The authors have not yet determined the results of these new efforts.