Safety of Inpatient Reconstructive Surgery Care

Improving quality of healthcare is a national priority and plastic surgery must participate in this movement.  To establish quality benchmarks, we must understand and define rates of adverse events for reconstructive procedures.  This project assessed risk-adjusted rates of inpatient adverse events for soft-tissue reconstructive procedures.

Inpatient data from 2005-2009 were extracted from the Nationwide Inpatient Sample, a database developed by the Agency for Healthcare Research and Quality (AHRQ).  Patients included were adults who had soft-tissue reconstructive procedure as their principal procedure.  Adverse events were identified using Patient Safety Indicators (PSI) which are established quality measures developed by AHRQ. All procedure and diagnosis codes were identified using ICD9-CM codes. Our comparison group was all other surgical patients. Rates reported were risk-adjusted PSIs per 1,000 patients at risk.

We found 385,272 hospital stays with soft tissue reconstruction as principal procedure and 17,723 (4.6%) had an adverse event during their hospital stay.  Some subpopulations had higher risk of PSI development, including older age, men, non-white, and Medicare or Medicaid payer (p<.05). Plastic surgery hospital volume was not associated with rates of PSI. Overall, PSI rates in reconstructive patients were lower than other surgical patients.  Plastic surgery had significantly lower rates for pressure ulcer (26.39 vs. 36.11), hemorrhage/hematoma (4.93 vs. 5.49), and pulmonary embolism/deep vein thrombosis (14.77 vs. 18.01), p<.05.  PSI risk adjusted rates were significantly higher for death among surgical in-patients with serious treatable conditions (163.02 vs. 128.26, p<.05). This result was almost solely driven by patients with burn diagnoses.  Burn patients had significantly higher rates of PSIs compared to other surgical inpatients. Size reduction (86.83) had significantly higher rates of hematoma hemorrhage but lower rates of DVT/PE. Patients with an attachment of pedicled graft (86.74) had significantly elevated rates of accidental puncture and laceration (16.57 vs. 6.43).

Soft tissue reconstructive surgery patients had lower PSI’s than other surgical disciplines, but PSIs were not uncommon.  Over this five-year period, 17,723 patients experienced at least one adverse event during their hospital stay.  These events lead to over eight percent excess mortality, more than double a patient’s length of stay and substantially increase associated hospital charges. With the establishment of the base rate of PSI’s, benchmarks can be devised and areas to target for improvement identified.