The American Journal of Surgery (2014) 208, 650-655

Clinical Science

Readmissions after ileostomy closure: causeto revisit a standardized enhanced recoverypathway?

Deborah S. Keller, M.S., M.D.a, Brian Swendseid, B.S.b, Sadaf Khan, M.D.a,Conor P. Delaney, M.D., M.Ch., Ph.D., F.R.C.S.I., F.A.C.S., F.A.S.C.R.S.a,*

aDivision of Colorectal Surgery, Department of Surgery, Unb

iversity Hospitals Case Medical Center,Cleveland, OH, USA; School of Medicine, Case Western Reserve University, Cleveland, OH, USA

KEYWORDS:Ileostomy;Enhanced recoverypathways;Patient outcomes;Readmission rates;Colorectal surgery

There were no relevant financial relat

in the form of grants, equipment, or dru

The authors declare no conflicts of i

* Corresponding author. Tel.: 11-2

7230.

E-mail address: Conor.Delaney@uhh

Manuscript received August 29, 201

15, 2013

0002-9610/$ - see front matter � 2014

http://dx.doi.org/10.1016/j.amjsurg.20

AbstractBACKGROUND: Our objective was to evaluate ileostomy reversal patients managed with a standard-

ized enhanced recovery pathway to identify factors associated with readmissions.METHODS: Prospective review database identified ileostomy reversal patients. Variables for the in-

dex admission and readmission were evaluated.RESULTS: Three hundred thirty-two patients were analyzed. The primary diagnosis was colorectal

cancer (57.6%). Thirteen percent of the patients were discharged by postoperative day (POD) 1, 47%by POD 2, and 65% by POD 3. The complication rate was 16.8%. The main complication was ileus/small bowel obstruction (n 5 27). Thirty-day readmission rate was 12.4% (n 5 41); small bowelobstruction (n 5 27) was the most frequent readmission diagnosis. The median readmission PODwas 7. Only 1 patient had a follow-up visit before readmission. The median readmission length ofstay was 4 days.

CONCLUSIONS: Most ileostomy reversal readmissions occur before the first follow-up and stemfrom preventable causes. An enhanced recovery pathway modification may improve outcomes and uti-lization in this group.� 2014 Elsevier Inc. All rights reserved.

Unplanned readmissions after colorectal surgery arecommon, unpredictable, and costly.1,2 Previous work hasattempted to identify the factors related to readmission.3–6

However, the predictive variables have not been well

ionships or any sources of support

gs.

nterest.

16-844-8087; fax: 11-216-983-

ospitals.org

3; revised manuscript December

Elsevier Inc. All rights reserved.

14.05.003

defined or successfully implemented to improve patientoutcomes. The benefit of an enhanced recovery pathway(ERP) on length of stay (LOS) and short-term outcomeshas been proven.7–18

Since 2000, our institution has developed, modified, andimplemented a standardized ERP and discharge criteria.These measures incorporate 5 core areas: pre- and post-operative patient information, preservation of gastrointes-tinal function, avoidance of organ dysfunction, active paincontrol, and promotion of patient autonomy. Our successin patient outcomes with the ERP has been previouslydescribed.7,11,19,20 The benefits of an ERP have been

D.S. Keller et al. ERP for ileostomy revision readmissions 651

demonstrated specifically for ileostomy reversal. Earlierstudies from our institution found a 9.5% readmission and4.8% reoperation rate within 30 days of closure.21 As ourERP has been refined, patients overall have realized thebenefit of early discharge with low readmission rates.22

However, the readmission rate after ileostomy reversal issignificantly higher. Thus, we recognized an opportunityto improve patient outcomes with the cohort of ileostomyreversal patients.

The objective of this study was to review patientsreadmitted after ileostomy reversal using an ERP. Ourhypothesis is that by identifying amendable variables, andincorporating these items in an ERP for that ileostomyreversal cohort, we may reduce complications, readmissionrates, and subsequent healthcare expenditures.

Patients and Methods

A retrospective review of an Institutional Review Board-approved prospective department database was performed toidentify patients who underwent an ileostomy reversal fromAugust 2006 to August 2012. The patients identified withCurrent Procedural Terminology codes 44,620, 44,625, and44,626 were considered for evaluation. Ileostomy reversalwas the primary procedure for the episode of care. Patientsunder 18 years of age, patients with colostomies, and thosewith incomplete medical records were excluded from thestudy. Patients were stratified as non-readmitted and read-mittedwithin 30 days of the ileostomy reversal. Preoperative,perioperative, and postoperative factors for the index admis-sion and readmission were included in the analysis. Addi-tional demographic and clinical information was extractedfrom the electronic medical records. Data extracted includedoperative reports to verify closure technique and case details,radiology reports, laboratory data, discharge summaries,emergency department visits, and follow-up visit results.Data fields evaluated for the index episode of care includedage, sex, body mass index, comorbidities, procedure type,procedure indication, hospital LOS, operative time, bloodloss, postoperative complications, and discharge disposition.For the readmission episode, additional data fields evaluatedincluded postoperative day (POD) of readmission, readmis-sion diagnosis, readmission LOS, white blood cell count,blood urea nitrogen (BUN), and creatinine levels at read-mission, reoperation rate at readmission and dischargedisposition.

Ileostomy closure

All closures were performed under general anesthesia. Acircumferential peristomal incision was made and deepeneddown to the fascia. The fascia was mobilized off the smallbowel. The small bowel was adequately mobilized to returnthe ileostomy closure site to the abdominal cavity. Thestoma was everted and the edges freshened. Depending onthe operating surgeon’s preference, the bowel was then

either closed transversely with interrupted sutures orresected with a side–side stapled anastomosis. The fasciawas closed with interrupted figure-of-eight sutures. Basedon surgeon’s preference, the ileostomy closure site waseither loosely stapled closed with a Penrose drain placed inthe cavity or partially closed with a subcuticular purse-string suture and betadine-soaked Telfa strips in the centralopening. The drain and packing strips were routinelyremoved on POD 2.

Definition of complications

Postoperative ileus was defined as lack of tolerance oforal diet or absence of stool by POD 3.23 Small bowelobstruction (SBO) was defined as symptoms of nausea,vomiting, constipation, or obstipation with radiographic ev-idence of SBO after initial return of bowel function, or me-chanical intestinal obstruction confirmed by laparotomy orcontrast study.24

Statistical analysis

Data analysis was completed using means, with standarddeviations, and medians, with ranges, as appropriate.

Results

Three hundred forty-five patients underwent ileostomyreversal during the study and were managed by astandardized ERP. Ten patients under 18 years of ageand 3 patients with incomplete medical records wereexcluded, leaving 332 patients included in the analysis.Fifty-four percent (n 5 178) were female. The medianage was 58 years (mean 55.49, range 19 to 88) and me-dian body mass index was 26 (mean 27.0, range 15 to51.3). The mean Charlson Comorbidity Index was 2.1,and most patients were American Society of Anesthesiol-ogists class 2 (n 5 147, 44.0%) or 3 (n 5 178, 54.0%)(Table 1). The primary diagnosis was colorectal cancer(57.6%), and the primary procedure performed was alow anterior resection (49.4%) (Table 2). The majorityof cases (n 5 316, 95%) were performed open, while4% were laparoscopic, and 1% laparoscopic convertedto open. The median operative time was 69 minutes(mean 82.9, range 31 to 312) and median blood losswas 15 mL (mean 35, range 0 to 1,000). Most patients(n 5 231, 70%) had a hand-sewn ileostomy closure. Thir-teen percent of patients were discharged by POD 1, 47%by POD 2, and 65% by POD 3. The complication rate was16.8% (n 5 56). The major complications were postoper-ative ileus/SBO (n 5 27, 44.3%), wound infection (n 510, 16.1%), and dehydration (n 5 five, 8.1%) (Table 3).Of the 10 wound infections, 7 were suture closed (7/231, 3.0%) and 3 were stapled (3/101, 3.0%).

The readmission rate within 30 days of operation was12.3% (n 5 41). The median POD of readmission was day

Table 1 Patient demographic, perioperative, and outcome data

Values n (%) Mean (SD) Median (range)

Count of cases 332Age 55.5 (17.0) 58 (19–88)Sex (female) 181 (54.0%)BMI 27.0 (6.46) 26 (15–51.3)Charlson score 2.10ASA1 4 (1.0%)2 147 (44.0%)3 178 (54.0%)4 3 (1.0%)

Hospital length of stay 4.3 (5.1) 3 (0–59)Operative time (minutes) 82.9 (51.5) 69 (31–312)Blood loss (mL) 35.0 (101.6) 15 (0–1,000)ICU stay required (days) 5 (2%)Ileostomy closureSutured 231 (70%)Stapled 101 (30%)

Postoperative complications 62 (18.7%)Small bowel obstruction/postoperative ileus 27 (43.5%)Wound infection 10 (16.1%)Dehydration 5 (8.1%)Bleeding/transfusion 3 (4.8%)Wound dehiscence 2 (3.2%)Anal stricture 2 (3.2%)Anastomotic leak 2 (3.2%)Infected PICC 2 (3.2%)Other* 9 (14.5%)

Mortality (30 days) 4 (1%)Readmitted (30 days) 41 (12.4%)Reoperation at readmission 12 (6%)

ASA 5 American Society of Anesthesiologists; BMI 5 body mass index; ICU 5 intensive care unit; PICC 5 peripherally inserted central catheter;

SD 5 standard deviation.

*Otherd1 each: ischemic colitis, Clostridium difficile colitis, sepsis, enterocutaneous fistula, end-stage renal disease, ostomy bleeding, pulmonary

embolism, pneumonia, and fluid collection.

Table 2 Indication for operation and procedure performed

n %

Primary diagnosisColorectal cancer/FAP 191 57.6Inflammatory bowel disease 121 36.2Diverticulitis 11 3.3Clostridium difficile colitis 4 1.2Ischemic colitis 3 .9Anal/ovarian/endometrial/vulvar cancer

6 1.8

Total 332 100Procedure where stoma createdLow anterior resection 164 49.4Total proctocolectomy,ileal pouch anal anastomosis

79 23.8

Total abdominal colectomy 55 16.6Segmental colectomy 28 8.4Other 6 1.8Total 332 100.0

FAP 5 familial adenomatous polyposis.

652 The American Journal of Surgery, Vol 208, No 4, October 2014

7 (mean 9.55, range 2 to 27). The most common indicationsfor readmission were SBO/postoperative ileus (n 5 27,41.5%) and dehydration (n 5 10, 24.4%). Seventeen pa-tients readmitted with SBO/postoperative ileus had a su-tured closure (17/27, 63%), while 10 had a stapledclosure (10/27, 37%). Seven readmitted patients (17%)received neoadjuvant therapy before their index operationand ileostomy reversal. At readmission, the median LOSwas 4 days (mean 7.78, range 0 to 45) (Table 3). Table 4details all readmission events; the POD of readmission,LOS, reoperation rate, and admitting laboratory values foreach individual diagnosis are shown. Only 1 of the 41 read-mitted patients (2.4%) had a postoperative follow-up visitbefore readmission. The majority of patients readmittedhad elevated BUN and creatinine levels.

Comments

In this study, we performed a critical evaluation ofpatients readmitted after ileostomy reversal. We found this

Table 3 Readmission episodes

Values for readmission episode n (%) Mean (SD) Median (range)

Readmitted (30 days) 41 (12.4%)Reoperation 12 (6%)LOS 7.78 (9.25) 4 (0–45)POD of readmission 9.55 (6.72) 7 (2–27)Urea nitrogen 21.62 (15.61) 15.5 (5–65)Creatinine 1.48 (1.12) .99 (.53–5.40)White blood cell count 9.9 (5.88) 8.35 (2.20–32.50)

LOS 5 length of stay; POD 5 postoperative day; SD 5 standard deviation.

D.S. Keller et al. ERP for ileostomy revision readmissions 653

cohort was amenable to early discharge, but readmissionrates were significant, even when compliant with astandardized ERP. Previous studies have shown that earlydischarge after ileostomy reversal is feasible. Kalady et al25

showed that ileostomy closure patients may be dischargedsafely after overnight observation, which reduces the useof hospital resources and decreases economic cost withoutcompromising care. In their 28-patient cohort, the meanhospital stay for the control population was 2.9 days,with the cost of the hospital stay at $3,811 versus $2,665in the experimental arm. Ihedioha et al also described thesafety of early discharge after ileostomy closure, with a me-dian LOS of 2 days and a range of 1 to 3 days. The overallcomplication rate and readmission rate were 18% and 12%,respectively.26 Joh et al21 reported a median hospital stay of2 days using standardized ERP in patients undergoingileostomy closure reiterating that the use of an EPR furtherenhances safe, early discharge.

However, high readmission and complication ratespersist. Kalady’s overnight observation group had a read-mission rate of 10.7%.25 In Ihedioha’s study, the overallcomplication rate was 18% and readmission rate was12%.26 Even with an ERP, Joh et al21 found that the 30-dayreadmission rate was 9.5% and the complication rate was23.8%. In spite of our refined standardized ERP anddischarge criteria, our ileostomy reversal readmission rate re-mains significantly higher than our overall readmission rate.Thus, there is room for process improvement to optimize pa-tient outcomes.

Ileostomy creation and reversal are associated withsignificant readmission rates for fluid and electrolyteabnormalities.27 Postoperative readmissions are beingrecognized as a marker of quality in surgical care. Addi-tionally, the need to improve readmission rates is para-mount as national healthcare law has been established topenalize hospitals Medicare determined had high 30-dayreadmission rates.28 A 12% readmission rate may no longerbe acceptable, especially if the readmissions are prevent-able. Thus, consideration of a customized ERP for theileostomy reversal group is logical. Lyon et al29 advocateda degree of individualization by patient group and proce-dures. The authors recognized that the evidence base forcomponents of most ERPs is changing, and supported amore flexible approach to incorporate evolving evidence-based data. Recognizing the high readmission rate for the

ileostomy group, Hayden et al27 also suggested differentdischarge criteria for select patients.

In our study, the majority of readmissions occurred afterPOD 6. Furthermore, almost all patients were readmittedbefore their follow-up visit with the operating surgeon. Weidentified that most patients were readmitted for dehydra-tion or SBO. Of the 27 patients readmitted with SBO/postoperative ileus, 17 patients had a sutured closure (17/27, 63%). However, the rate of overall sutured closures washigher (231, 70%). Thus, the total percent of suturedclosures that was readmitted with SBO was 17/231(7.4%), lower than stapled closures (10/101, 9.9%). Thus,it is not clear that one type of closure is a risk factor for thiscomplication and further study will need to be focused onevaluating the impact of closure techniques. These patientshad elevated BUN and creatinine levels at readmission.Based on these findings, we believe that contacting patientswithin 1 week after reversal to assure adequate per oral(PO) intake, urinary output, stool, and ostomy output (ifapplicable) could assure adequate hydration and reduceunnecessary readmissions. Incorporating a narcotic sparinganalgesic program into the discharge instructions for thispatient population may also help reduce the rate of post-operative ileus. Further prospective studies will evaluateimprovements from this change to our standard practice.

We do recognize limitations of this study. The design isretrospective, and subject to the biases associated withretrospective studies. Furthermore, we were unable toanalyze specific aspects of the patients’ postoperativecourse, such as the use of Lomotil, if not detailed in themedical records. Patients treated and admitted outside ofour healthcare system are not captured, which could affectour analysis and results. It is also a single-institution study,so our results may not be generalizable. Regardless of anylimitations, the study describes a clinically relevant issuethat affects all providers, and any attempts to improvepatient outcomes and readmission rates are critical in thecurrent healthcare environment.

In conclusion, ileostomy reversals continue to be asource of higher readmission and healthcare utilization.Most of these readmissions occur before the first follow-upvisit, and many stem from preventable causes. Given therecognition, a change in our ERP will be made to contactpatients within 7 days of hospital discharge to assureadequate fluid intake and address any other care-related

Table

4Readmissionepisodes

byindividual

diagnosis

Readmissiondiagnosis

Length

ofstay

Postoperativeday

Reoperation

BUN

Creatinine

WBC

Median(range)

Mean(SD)

Median(range)

Mean(SD)

n(%

)Mean(SD)

Mean(SD)

Mean(SD)

SBO/POI(n

517)

5(1–27)

7.58(7.19)

6.5

(2–27)

9.44(8.27)

3(18%)

15.86(9.74)

1.04(.66)

6.59(2.56)

Dehydration(n

510)

2.5

(1–23)

5.7

(6.9)

6.5

(3–18)

8(5.2)

2(20%)

26(7.65)

2.1

(.79–3.3)

12.48(4.59)

Woundinfection(n

54)

2(1–18)

5.75(8.22)

9(5–16)

9.75(4.6)

d23.33(22.68)

2.353(2.64)

12.23(5.49)

Ostomybleeding(n

53)

4(4–6)

4.67(1.3)

13(5–18)

11(5.92)

d11(2.12)

.99(.08)

10.45(3.18)

Anastomoticleak

(n5

2)

2.5

(1–4)

2.5

(2.12)

11.5

(3–20)

11.5

(12.02)

2(100%)

13.5

(9.19)

.93(.24)

12.4

(3.67)

Wounddehiscence/bleeding(n

51)

21

21

55

1(100%)

19

.67

6.8

Peritonitis

(n5

1)

21

21

14

14

1(100%)

13

1.49

32.5

ECF(n

51)

45

45

17

17

1(100%)

47

.97

11.7

Fluid

collection(n

51)

66

17

17

1(17%)*

9.64

11.4

Ischem

icbowel

(n5

1)

22

33

1(100%)

44

4.04

2.2

BUN5

bloodureanitrogen;Cr

5creatinine;

ECF5

enterocutaneousfistula;IR

5interventional

radiology;

POI5

postoperative

ileus;SB

O5

smallbowel

obstruction;SD

5standarddeviation;WBC5

whitebloodcell.

*IR

drainage.

654 The American Journal of Surgery, Vol 208, No 4, October 2014

issues that may reduce readmissions after ileostomyreversal. Further prospective study will evaluate the patientand financial benefit from customizing the ERP afterileostomy reversal.

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