Reducing Readmissions Post-tonsillectomy: A Quality Improvement Study on Intravenous Hydration

Hession-Laband, Eileen; Melvin, Patrice; Shermont, Herminia; Murphy, Jane M.; Bukoye, Bola; Amin, Manali

doi:10.1097/jhq.0000000000000143

Cited by 10 publications

(9 citation statements)

References 25 publications

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“…After the implementation of a hydration protocol, the ED visits due to dehydration decreased to 0.2% from 1%. 12 In our Open access study, 2.6% of children had an ED visit, and 5.9% had a HA due to dehydration. The implementation of hydration protocols for all paediatric ambulatory surgeries may be helpful in reducing these ED visits and HA.…”

Section: Discussionmentioning

confidence: 64%

“…A quality improvement study that focused on intravenous hydration examined ED visits due to dehydration in children who underwent ambulatory tonsillectomy prior to and after the implementation of the protocol. 12 Younger patients and patients with pre-existing complex chronic conditions were at higher risk of dehydration. After the implementation of a hydration protocol, the ED visits due to dehydration decreased to 0.2% from 1%.…”

Section: Discussionmentioning

confidence: 99%

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Emergency department use and hospital admission in children following ambulatory surgery: a retrospective population-based cohort study

Sawhney

VanDenKerkhof

Goldstein

et al. 2021

bmjpo

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IntroductionPaediatric ambulatory surgery (same day surgery and planned same day discharge) is more frequently being performed more in Canada and around the world; however, after surgery children may return to hospital, either through the emergency department (ED) or through a hospital admission (HA). The aim of this study was to determine the patient characteristics associated with ED visits and HA in the 3 days following paediatric ambulatory surgery.MethodsThis population-based retrospective cohort study used de-identified health administrative database housed at ICES and included residents of Ontario, younger than 18 years of age, who underwent ambulatory surgery between 2014 and 2018. Patients were not involved in the design of this study. The proportion of ED visit and HA were calculated for the total cohort, and the type of surgery. The ORs and 95% CIs were calculated for each outcome using logistic regression.Results83 468 children underwent select ambulatory surgeries. 2588 (3.1%) had an ED visit and 608 (0.7%) had a HA in the 3 days following surgery. The most common reasons for ED visits included pain (17.2%) and haemorrhage (10.5%). Reasons for HA included haemorrhage (24.8%), dehydration (21.9%), and pain (9.1%).ConclusionsOur findings suggest that pain, bleeding and dehydration symptoms are associated with a return visit to the hospital. Implementing approaches to prevent, identify and manage these symptoms may be helpful in reducing ED visits or hospital admissions.

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Section: Discussionmentioning

confidence: 64%

Section: Discussionmentioning

confidence: 99%

Emergency department use and hospital admission in children following ambulatory surgery: a retrospective population-based cohort study

Sawhney

VanDenKerkhof

Goldstein

et al. 2021

bmjpo

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“…This was supported by our statistical analysis where there was an increased chance of secondary PTH in children (OR 2.3) and adults (OR 3.8) when BiZact™ tonsillectomy was performed by a trainee, compared to a consultant. Several other small‐scale studies have also demonstrated an association between surgeon experience and PTH, 9,18–21 with trainees having higher PTH rates compared to consultants. Furthermore, a decrease in PTH rates over time that the BiZact™ device was used suggests a learning curve exists, with experience gained leading to decreasing risk of PTH occurring.…”

Section: Discussionmentioning

confidence: 89%

BiZact™ tonsillectomy: Predictive factors for post‐tonsillectomy haemorrhage from a 1717 case series

Mao

Woods

Athanasiadis

et al. 2023

Clinical Otolaryngology

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Objective: To determine primary and secondary post-tonsillectomy haemorrhage (PTH) rates and identify predictive factors in a cohort of consecutive adult and paediatric BiZact™ tonsillectomy cases. Setting: Retrospective cohort study. Patients from Flinders Medical Centre, Noarlunga Hospital and private otolaryngology practices who underwent BiZact™ tonsillectomy from 2017 to 2020. Data collected: patient age, indication for tonsillectomy, surgeon experience, time and severity of PTH, including return to theatre. Each secondary PTH was graded using the Stammberger classification. Logistic regression was utilised to identify predictors of secondary PTH.Results: One thousand seven hundred and seventeen patient medical records were assessed (658 adults and 1059 children). The primary PTH rate was 0.1%, and secondary PTH rate was 5.9%. The majority of secondary PTH cases were Stammberger grade A (80/102, 78.4%) requiring observation only. Few secondary PTH required medical intervention (grade B; 9/102, 8.8%), return to theatre (grade C; 12/102, 11.8%), or blood transfusion (grade D; 1/102, 1.0%), with no death reported (grade E; 0/102, 0.0%). Recurrent secondary PTH occurred in 8 patients (0.5%). Predictive factors of secondary PTH in children were surgeon experience with trainees having greater chance of PTH (OR 2.502, 95% CI 1.345-4.654; p = .004) and age of child (OR 1.095, 95% CI 1.025-1.170; p = .007). Surgeon experience was a predictive factor for adults (OR 3.804, 95% CI 2.139-6.674; p < .001).Conclusions: BiZact™ tonsillectomy has a low primary PTH rate, with a secondary PTH rate comparable to other 'hot tonsillectomy' techniques. The majority of PTH events were minor and self-reported. There appears to be a learning curve for trainee surgeons.

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“…Although the mechanism is unclear, there is a hypothesis that the tonsillar fossa heals by secondary intention, and bleeding can occur when the wound sloughs. A relatively dry oropharynx (from inadequate hydration) can compound the propensity for bleeding . Older children and adolescents who tend to maintain hydration status well enough to prevent gross signs of dehydration may have relative dehydration, hence more secondary bleeding than younger children who present earlier with dehydration .…”

Section: Discussionmentioning

confidence: 99%

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

Johnson

Beams

Zaniletti

et al. 2023

JAMA Otolaryngol Head Neck Surg

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ImportanceThe American Academy of Otolaryngology–Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored.ObjectiveTo use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event.Design, Settings, and ParticipantsThis retrospective cohort study used data from the Pediatric Health Information System for all pediatric (&lt;18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children’s hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023.Main Outcomes and MeasuresRevisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy.ResultsOf the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%.Conclusions and RelevanceThis retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

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Reducing Readmissions Post-tonsillectomy: A Quality Improvement Study on Intravenous Hydration

Abstract: The hydration initiative was associated with a significant decrease in hospital readmissions. This safe, low-cost, easy-to-implement approach to preventing dehydration post-tonsillectomy could be explored at other institutions.

Cited by 10 publications

References 25 publications

Emergency department use and hospital admission in children following ambulatory surgery: a retrospective population-based cohort study

Emergency department use and hospital admission in children following ambulatory surgery: a retrospective population-based cohort study

BiZact™ tonsillectomy: Predictive factors for post‐tonsillectomy haemorrhage from a 1717 case series

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

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