Sunday, January 28, 2018

Avoiding emergency visits after outpatient rotator cuff repair. Lessons learned

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair:potential for avoidance

These authors reviewed 1306 outpatient RCR procedures in a closed health care system, and all unplanned emergency department (ED) and urgent care (UC) visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction).

Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention.

Of the 729 male and 577 female patients; average age, 60 years, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). 

Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common, whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied.

Comment: What is interesting about this paper is the actions the physicians in the system took to minimize the number of avoidable unplanned visits after cuff repair:

Preoperatively, patients receive counseling on pain management, constipation prevention, and return precautions. They are given prescriptions for postoperative pain to be filled the day before surgery. 

They recommended a single 375-mL glass of a high-carbohydrate clear liquid (eg, apple juice) up to 2 hours before arrival for surgery is used to help prevent constipation, nausea, and vomiting. 

Multimodal analgesia with acetaminophen, gabapentin, and a nonsteroidal antiinflammatory drug is started preoperatively for increased pain control and reduction of constipation, urinary retention risk, nausea, and vomiting. 

Perioperatively, monitored anesthesia care is preferred over general anesthesia whenever possible, and local anesthesia or field blocks are encouraged. 

Intravenous fluid restriction to less than 500 mLis also attempted to decrease the risk of urinary retention. 

Before discharge from the postanesthesia care unit, a concerted effort is made to ensure that a stool softener or laxative is prescribed for the patient.

This is a great example of a robust effort to identify issues with quality of patient care and cost, followed by a plan to address the problems identified.