Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care

Abstract

Background Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors' prior retrospective review identified endocrinology follow-up as protective factor.

Objectives Implementation of a multidisciplinary postoperative care (POC) pathway: (1) to reduce 30-day hospital readmissions following ETPS and (2) improve inpatient and outpatient coordination of care with endocrinologist.

Methods This study is a single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized postdischarge 1 to 1.5 L/d fluid restriction, postoperative days 5 to 7 serum sodium, and endocrinology follow-up within 1 week of discharge to stratify patients into tiered hyponatremia regimens.

Results A total of 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All-cause readmission was significantly reduced following implementation of the POC pathway (14 vs. 6%, p = 0.015). Coordination with endocrinologist significantly increased in the inpatient (96 vs. 83%, p < 0.001) and outpatient (77 vs. 68%, p = 0.042) settings. Patients who were not in the POC pathway had the highest risk of readmission (odds ratio: 2.5; 95% confidence interval: 1.1–5.5).

Conclusion A multidisciplinary POC pathway incorporating endocrinologist in conjunction with postdischarge weight-based fluid restriction and postoperative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

Keywords

quality improvement - postoperative care pathway - readmissions - transsphenoidal pituitary surgery - pituitary surgery - risk factors - endocrinology - coordination of care

Note

Interim results of this study were presented at the 31st Annual North American Skull Base Society Meeting in Phoenix, Arizona, United States.

Publication History

Received: 31 December 2021

Accepted: 29 July 2022

Accepted Manuscript online:
05 August 2022

Article published online:
07 October 2022

• References

• 1 Chibbaro S, Ganau M, Gubian A. et al. The role of endoscopic endonasal approach in the multimodal management of giant pituitary adenoma: case report and literature review. Asian J Neurosurg 2018; 13 (03) 888-892
• 2 Gittleman H, Ostrom QT, Farah PD. et al. Descriptive epidemiology of pituitary tumors in the United States, 2004-2009. J Neurosurg 2014; 121 (03) 527-535
• 3 Gondim JA, Almeida JP, Albuquerque LA. et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 2011; 14 (02) 174-183
• 4 Messerer M, Cossu G, George M, Daniel RT. Endoscopic endonasal trans-sphenoidal approach: minimally invasive surgery for pituitary adenomas. J Vis Exp 2018; (131) 55896
• 5 Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol 2014; 4 (09) 767-770
• 6 Alzhrani G, Sivakumar W, Park MS, Taussky P, Couldwell WT. Delayed complications after transsphenoidal surgery for pituitary adenomas. World Neurosurg 2018; 109: 233-241
• 7 Chowdhury T, Prabhakar H, Bithal PK, Schaller B, Dash HH. Immediate postoperative complications in transsphenoidal pituitary surgery: a prospective study. Saudi J Anaesth 2014; 8 (03) 335-341
• 8 Fan YP, Lv MH, Feng SY. et al. Full endoscopic transsphenoidal surgery for pituitary adenoma-emphasized on surgical skill of otolaryngologist. Indian J Otolaryngol Head Neck Surg 2014; 66 (Suppl. 01) 334-340
• 9 Carminucci AS, Ausiello JC, Page-Wilson G. et al. Outcome of implementation of a multidisciplinary team approach to the care of patients after transsphenoidal surgery. Endocr Pract 2016; 22 (01) 36-44
• 10 Bur AM, Brant JA, Newman JG. et al. Incidence and risk factors for prolonged hospitalization and readmission after transsphenoidal pituitary surgery. Otolaryngol Head Neck Surg 2016; 155 (04) 688-694
• 11 Hendricks BL, Shikary TA, Zimmer LA. Causes for 30-day readmission following transsphenoidal surgery. Otolaryngol Head Neck Surg 2016; 154 (02) 359-365
• 12 Cote DJ, Dasenbrock HH, Muskens IS. et al. Readmission and other adverse events after transsphenoidal surgery: prevalence, timing, and predictive factors. J Am Coll Surg 2017; 224 (05) 971-979
• 13 Barber SM, Liebelt BD, Baskin DS. Incidence, etiology and outcomes of hyponatremia after transsphenoidal surgery: experience with 344 consecutive patients at a single tertiary center. J Clin Med 2014; 3 (04) 1199-1219
• 14 Graboyes EM, Kallogjeri D, Saeed MJ, Olsen MA, Nussenbaum B. Postoperative care fragmentation and thirty-day unplanned readmissions after head and neck cancer surgery. Laryngoscope 2017; 127 (04) 868-874
• 15 Rizvi ZH, Ferrandino R, Luu Q, Suh JD, Wang MB. Nationwide analysis of unplanned 30-day readmissions after transsphenoidal pituitary surgery. Int Forum Allergy Rhinol 2019; 9 (03) 322-329
• 16 Shaftel KA, Cole TS, Little AS. National trends in hospital readmission following transsphenoidal surgery for pituitary lesions. Pituitary 2020; 23 (02) 79-91
• 17 Younus I, Gerges MM, Dobri GA, Ramakrishna R, Schwartz TH. Readmission after endoscopic transsphenoidal pituitary surgery: analysis of 584 consecutive cases. J Neurosurg 2019; 1-6
• 18 Ghiam MK, Chyou DE, Dable CL. et al. 30-day readmissions and coordination of care following endoscopic transsphenoidal pituitary surgery: experience with 409 patients. J Neurol Surg B Skull Base 2021; 83 (Suppl. 02) e410-e418
• 19 Krogh J, Kistorp CN, Jafar-Mohammadi B, Pal A, Cudlip S, Grossman A. Transsphenoidal surgery for pituitary tumours: frequency and predictors of delayed hyponatraemia and their relationship to early readmission. Eur J Endocrinol 2018; 178 (03) 247-253
• 20 Bohl MA, Ahmad S, Jahnke H. et al. Delayed hyponatremia is the most common cause of 30-day unplanned readmission after transsphenoidal surgery for pituitary tumors. Neurosurgery 2016; 78 (01) 84-90
• 21 Woodmansee WW, Carmichael J, Kelly D, Katznelson L, Neuroendocrine A. AACE Neuroendocrine and Pituitary Scientific Committee. Pituitary scientific C. American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: postoperative management following pituitary surgery. Endocr Pract 2015; 21 (07) 832-838
• 22 Olson BR, Gumowski J, Rubino D, Oldfield EH. Pathophysiology of hyponatremia after transsphenoidal pituitary surgery. J Neurosurg 1997; 87 (04) 499-507
• 23 Hensen J, Henig A, Fahlbusch R, Meyer M, Boehnert M, Buchfelder M. Prevalence, predictors and patterns of postoperative polyuria and hyponatraemia in the immediate course after transsphenoidal surgery for pituitary adenomas. Clin Endocrinol (Oxf) 1999; 50 (04) 431-439
• 24 Jahangiri A, Wagner J, Tran MT. et al. Factors predicting postoperative hyponatremia and efficacy of hyponatremia management strategies after more than 1000 pituitary operations. J Neurosurg 2013; 119 (06) 1478-1483
• 25 Taylor SL, Tyrrell JB, Wilson CB. Delayed onset of hyponatremia after transsphenoidal surgery for pituitary adenomas. Neurosurgery 1995; 37 (04) 649-653 , discussion 653–654
• 26 Winograd D, Staggers KA, Sebastian S, Takashima M, Yoshor D, Samson SL. An effective and practical fluid restriction protocol to decrease the risk of hyponatremia and readmissions after transsphenoidal surgery. Neurosurgery 2020; 87 (04) 761-769
• 27 Deaver KE, Catel CP, Lillehei KO, Wierman ME, Kerr JM. Strategies to reduce readmissions for hyponatremia after transsphenoidal surgery for pituitary adenomas. Endocrine 2018; 62 (02) 333-339
• 28 Takeuchi K, Nagatani T, Okumura E, Wakabayashi T. A novel method for managing water and electrolyte balance after transsphenoidal surgery: preliminary study of moderate water intake restriction. Nagoya J Med Sci 2014; 76 (1-2): 73-82
• 29 Matsuyama J, Ikeda H, Sato S, Yamamoto K, Ohashi G, Watanabe K. Early water intake restriction to prevent inappropriate antidiuretic hormone secretion following transsphenoidal surgery: low BMI predicts postoperative SIADH. Eur J Endocrinol 2014; 171 (06) 711-716
• 30 Burke WT, Cote DJ, Iuliano SI, Zaidi HA, Laws ER. A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery. Pituitary 2018; 21 (01) 25-31
• 31 Bohl MA, Ahmad S, White WL, Little AS. Implementation of a postoperative outpatient care pathway for delayed hyponatremia following transsphenoidal surgery. Neurosurgery 2018; 82 (01) 110-117
• 32 Conger A, Zhao F, Wang X. et al. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 2018; 130 (03) 861-875
• 33 Umamaheswaran P, Krishnaswamy V, Krishnamurthy G, Mohanty S. Outcomes of surgical repair of skull base defects following endonasal pituitary surgery: a retrospective observational study. Indian J Otolaryngol Head Neck Surg 2019; 71 (01) 66-70
• 34 Snyder MH, Asuzu DT, Shaver DE, Vance ML, Jane JA. Routine postoperative fluid restriction to prevent syndrome of inappropriate antidiuretic hormone secretion after transsphenoidal resection of pituitary adenoma. J Neurosurg 2021; 136 (02) 405-412