Causes of 30-day readmission after aneurysmal subarachnoid hemorrhage

Abstract

OBJECTIVE Hospital readmission is a common but controversial quality measure increasingly used to influence hospital compensation in the US. The objective of this study was to evaluate the causes for 30-day hospital readmission following aneurysmal subarachnoid hemorrhage (SAH) to determine the appropriateness of this performance metric and to identify potential avenues for improved patient care. METHODS The authors retrospectively reviewed the medical records of all patients who received surgical or endovascular treatment for aneurysmal SAH at Barnes-Jewish Hospital between 2003 and 2013. Two senior faculty identified by consensus the primary medical/surgical diagnosis associated with readmission as well as the underlying causes of rehospitalization. RESULTS Among 778 patients treated for aneurysmal SAH, 89 experienced a total of 97 readmission events, yielding a readmission rate of 11.4%. The median time from discharge to readmission was 9 days (interquartile range 3–17.5 days). Actual hydrocephalus or potential concern for hydrocephalus (e.g., headache) was the most frequent diagnosis (26/97, 26.8%), followed by infections (e.g., wound infection [5/97, 5.2%], urinary tract infection [3/97, 3.1%], and pneumonia [3/97, 3.1%]) and thromboembolic events (8/97, 8.2%). In most cases (75/97, 77.3%), we did not identify any treatment lapses contributing to readmission. The most common underlying causes for readmission were unavoidable development of SAH-related pathology (e.g., hydrocephalus; 36/97, 37.1%) and complications related to neurological impairment and immobility (e.g., thromboembolic event despite high-dose chemoprophylaxis; 21/97, 21.6%). The authors determined that 22/97 (22.7%) of the readmissions were likely preventable with alternative management. In these cases, insufficient outpatient medical care (for example, for hyponatremia; 16/97, 16.5%) was the most common shortcoming. CONCLUSIONS Most readmissions after aneurysmal SAH relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric.

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

“…3,4,14,15,25 In addition, it is the most common cause of readmission after aSAH. 13 CSF shunting is prone to short-and long-term complications, including life-threatening obstructions and infections. 15 Studies have found that shunting after aSAH related to acute hydrocephalus, 2 Figure).…”

“…12,13 Therefore, it is important to identify and understand the factors that increase risk for shunting and to eliminate or mitigate the reversible factors that put aSAH patients at risk. Also, recognition of predictive variables and identifying patients at risk for shunt-dependent hydrocephalus (SDHCP) could lead to optimized management with avoidance of increased neurological morbidity, impaired functional outcome and quality of life, and extended hospital stays associated with chronic hydrocephalus.…”

Potentially Preventable 30-Day Hospital Readmissions at a Children’s Hospital

“…Because of the complexity of assessing preventability, we used a consensus review process similar to that used in other readmission-preventability studies. 13,20,21 Each case had 1 primary reviewer, with no fewer than 3 pediatricians participating in the consensus review. In circumstances in which the readmission involved significant subspecialty care (eg, congenital heart disease postoperative management), relevant subspecialists were consulted.…”

Early versus late readmission of subarachnoid haemorrhage patients into neurocritical care

“…Patients can suffer from electrolyte abnormalities, 2-5 delayed cerebral ischaemia (DCI), 6-8 further bleeding 9,10 and infection. 11,12 These complications are not uncommon, and have been associated with a worse clinical outcome. 13 Once admitted into NCCU, there is no set time period for how long SAH patients should remain for monitoring.…”