Assessing early unplanned reoperations in neurosurgery: opportunities for quality improvement

Abstract

By the nature of the underlying conditions and the corrective procedure, surgical patients are exposed to a variety of risks. Despite oftentimes relatively low complication rates, the median incidence of inpatient adverse events has been estimated at 9%-10%, with operation-related events constituting almost 40% of those events, across all surgical specialties within an institution. 8,14 Across surgical specialties, multiple prospective and retrospective studies have reported best-case scenario outcomes and complication rates specific to particular entities and procedures. 25 Importantly, neurosurgery has relatively high morbidity and mortality rates in comparison with other surgical specialties. 15 Review of morbidities and mortality has been the primary method of assessing surgical quality used by physicians, hospitals, and oversight agencies. 10,17,20 In recent years, the reoperation rate, defined as the percentage of patients undergoing a new operation, has been proposed as a quality indicator, a surrogate for surgical adverse events. 4,13,19,24 General surgery has been at the forefront of assessing reoperations. Reported rates have varied widely (0.6% to 9.4%) depending on the definition, method of detection, case selection criteria, heterogeneity of practices, and difference in department and hospital practic- OBJect Review of morbidities and mortality has been the primary method used to assess surgical quality by physicians, hospitals, and oversight agencies. The incidence of reoperation has been proposed as a candidate quality indicator for surgical care. The authors report a comprehensive assessment of reoperations within a neurosurgical department and discuss how such data can be integrated into quality improvement initiatives to optimize value of care delivery. methOdS All neurosurgical procedures performed in the main operating room or the outpatient surgery center at the Ronald Reagan UCLA Medical Center and UCLA Santa Monica Medical Center from July 2008 to December 2012 were considered for this study. Interventional radiology and stereotactic radiosurgery procedures were excluded. Early reoperations within 7 days of the index surgery were reviewed and their preventability status was evaluated. reSultS The incidence of early unplanned reoperation was 2.6% (occurring after 183 of 6912 procedures). More than half of the patients who underwent early unplanned reoperation initially had surgery for shunt-related conditions (34.4%) or intracranial tumor (23.5%). Shunt failure was the most common indication for early unplanned reoperation (34.4%), followed by postoperative bleeding (20.8%) and postoperative elevated intracranial pressure (9.8%). The average time interval (± SD) between the index surgery and reoperation was 3.0 ± 1.9 days. The average length of stay following reoperation was 12.1 ± 14.4 days. cONcluSiONS This study enabled an in-depth assessment of reoperations within an academic neurosurgical practice and identification of strategic opportunities for department-wide quality improvement in...

Perioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program–Pediatrics

“…There is an increased emphasis to include unplanned reoperation measures into surgical quality assessments, which is especially pertinent in pediatric and adult neurosurgery where high rates of reoperation often are required to address important complications, such as postoperative intracranial bleeding and shunt failures. 9,10,19 In addition, we found the composite morbidity for craniotomy/craniectomy and defect repairs higher than previously reported. 15 These 2 procedures had high rates of bleeding, requiring transfusion and ventilator dependence > 24 hours.…”

“…In addition, unplanned reoperation, which traditionally has not been included in measures of composite morbidity, was evaluated as an individual outcome, given its increasing use as a proxy for surgical quality in neurosurgery. 9,10,19 Unplanned reoperation as defined by the NSQIP-Peds protocol excludes cases with preoperative or intraoperative documentation that specifies the need for a patient to return to the operating room following the principal operative procedure, such as return to the operating room for planned CSF diversion following repair of a spinal defect. Finally, we summarized patients who experienced any of the previously mentioned AEs, including unplanned reoperation.…”

The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery

“…8 They then went on to show that the most common indication for early (i.e., within 7 days) unplanned reoperation was shunt failure (63 [34.4%] of 183 cases). 30 As a result of this, the department has set-up process-improvement ideas to reduce reoperation rates, such as defining the use of intraoperative navigation for proximal catheter placement, endoscopy for distal catheter placement, intraoperative confirmation of shunt position, and standardizing the use of intrathecal antibiotics.…”

Isolated platelet concentrate transfusion during surgery: a single‐center observational cohort study

“…Our most notable study finding is a higher‐than‐anticipated rate of bleeding complications in patients receiving isolated PCs. Prior studies describe a 1% to 7% rate of unplanned reoperation for bleeding in cardiac and neurosurgery patients . In one large contemporary study of cardiac surgery patients, the rate of reoperation for bleeding was 3% .…”

“…Prior studies describe a 1% to 7% rate of unplanned reoperation for bleeding in cardiac and neurosurgery patients. [11][12][13][14][15][16][17] In one large contemporary study of cardiac surgery patients, the rate of reoperation for bleeding was 3%. 18 These rates are significantly lower than the 22.9% overall bleeding complication rate observed in our study and the 13.4% bleeding complication rate observed in cardiac surgery patients in our study.…”