Presentation
PS13 - Toward a Post-Discharge Patient Safety Intervention for Chronic Limb-Threatening Ischemia: A Scoping Review
DescriptionChronic limb-threatening ischemia (CLTI) is the most severe stage of peripheral arterial disease (PAD) and affects about 2 million Americans per year(1). CLTI patients suffer from a high burden of adverse outcomes including a 22% one-year mortality rate(2), myocardial infarction (MI) and stroke(3), limb loss(2), and a very low quality of life(4). If left untreated, CLTI can be fatal(5).
Treatment for CLTI is surgical, via revascularization (or limb amputation in more advanced cases). The recovery period from CLTI procedures is long and complicated by the advanced age(6) and comorbidities(5,6) of the patient population. Despite several innovations in CLTI management, issues with patient safety abound (7): 30-day readmissions and emergency department (ED) visits occur in 20-30% of patients(8), largely due to postoperative complications such as systemic and surgical site infections (23.5%), continued progression of chronic limb ischemia (22.2%), and cardiac events (11.4%)(8). Additionally, nonadherence to medication regimens and follow-up appointments are common occurrences with CLTI patients (9).
A major challenge toward improving postoperative patient safety and outcomes in this patient population is that a large proportion of these issues—including 77% of postoperative wound infections(10)—occur post-discharge (11), where providers have little oversight. This issue is compounded by the multidisciplinary nature of CLTI care(12), involving various specialists and healthcare professionals (e.g., vascular surgeons, primary care providers, endocrinologists, skilled nursing facility personnel, physical therapists, home health nurses). Furthermore, 25% of CLTI readmissions occur at a different hospital from where the patient originally underwent surgery (13). This fragmented communication and uncoordinated care leads to poor patient safety due to challenges for vascular surgeons to fully understand all aspects that contribute to patients’ complications.
Altogether, the CLTI domain represents an area ripe for development of a post-discharge support intervention in order to improve patient safety and patient outcomes. We hypothesized that several of the common postoperative complications in this area are widely preventable or intervenable to stop progression (e.g., via wound care, medication adherence, and symptom monitoring). As a first step, we conducted a scoping review to identify known factors that were associated with post-discharge complications and patient safety events in this population.
Methods
We searched various electronic databases including PubMed and Google Scholar. The search was limited to articles discussing CLTI patients who had already undergone or were planned to undergo surgical intervention. The following search terms and keywords were used in this search with the appropriate Boolean operators: “chronic limb-threatening ischemia,” or “critical limb ischemia,” and “complications,” or “outcomes,” or “mortality,” or “readmission,” or “hospitalization,” or “rehospitalization,” and “predict,” or “predictors.” Additionally, the terms “surgery,” or “revascularization,” or “bypass,” or “procedure,” and “infection,” or “bleeding,” or “cardiac,” were included in later database searches.
The screening process involved reviewing the title, abstract, and full text when applicable to determine whether studies met inclusion criteria. Articles were excluded if they were not related to the predictors of outcomes and complications for CTLI patients undergoing surgical intervention. Additionally, studies were excluded if they were not available in English.
We systematically extracted data on the study methods, sample size, sample type, surgery type (e.g., bypass, amputation, endovascular revascularization, etc.), outcomes examined, predictors of outcomes examined, and overall findings.
Results
The initial search yielded a total of 3,879 studies. After screening, 27 studies remained, with
1,747,725 patients in total. The most examined postprocedural CLTI patient safety outcomes were mortality (k=10, 37%), limb loss (k=9, 33%), and readmission (k=4, 15%).
The most commonly identified predictors of mortality and limb loss in this population were medical comorbidities (k=6), particularly diabetes mellitus (k=2) and heart disease (k=2). Additional factors including wound severity (k=2) and malnourishment or frailty (k=2) were also found to be positively associated with these poor outcomes. Readmission was most associated with patients ≥65 years old (k=2) and females (k=2). Various comorbidities attributed to readmission including coronary artery disease, heart failure, diabetes mellitus, chronic kidney disease, ulcers or gangrene, anemia, obesity, and prior amputation (k=1). Additionally, perioperative events such as major bleeding (k=1), sepsis (k=1), and acute myocardial infarction (k=1) were predictors of readmission for CLTI patients. Patients’ travel time to the hospital was positively associated with readmission (k=1). Wound complications were positively predicted by surgical or hybrid modalities for revascularization (k=1). Infections were positively predicted by preoperative length of stay (k=1) and history of endovascular procedures (k=1).
Alternatively, postprocedural dual-antiplatelet therapy (k=1), surgical modalities for patients with great saphenous vein access (k=1), and endovascular modalities in malnourished patients (k=1) were found to have an inverse relationship with patient safety outcomes. Modality choice for revascularization did not significantly predict readmission (k=1). Private insurance status was found to a have negative correlation with readmission (k=1).
Discussion
Overall, comorbidities were the most commonly noted predictors of poor patient safety outcomes for CLTI patients post-surgical intervention, including mortality, limb loss, and readmission. Towards the development of a post-discharge intervention to improve patient safety in this patient population, this scoping review identified some characteristics of the population to consider focusing such an intervention on, including patients with comorbidities (particularly diabetes and heart disease), those with severe surgical wounds, those who are malnourished or frail, patients ≥65 years old, and females. However, there is little consistency in the relationships studied within the current literature and thus it was challenging to identify specific patterns and themes of outcomes and complications for CLTI patients. Additionally, there seems to be a lack of literature addressing the impact of the social determinants of health on outcomes for CLTI patients. Factors such as rurality of residency and degree of caregiver support may have significant implications in the overall care of patients but are currently understudied in regards to CLTI. The sparse literature base in these areas complicates the effort to determine the most effective intervention to target this problem.
As such, future research should continue to establish patterns amongst the various complications and negative outcomes experienced by CLTI patients. There should also be an increased focus on the social aspect of care for CLTI patients. Collecting such data may help better identify potential points of intervention to prevent further harm and improve patient outcomes. Toward this goal, our future work will continue to examine these issues via additional methods, including surveying physicians, patients, and developing machine learning models to examine outcomes with electronic health record (EHR) data.
Treatment for CLTI is surgical, via revascularization (or limb amputation in more advanced cases). The recovery period from CLTI procedures is long and complicated by the advanced age(6) and comorbidities(5,6) of the patient population. Despite several innovations in CLTI management, issues with patient safety abound (7): 30-day readmissions and emergency department (ED) visits occur in 20-30% of patients(8), largely due to postoperative complications such as systemic and surgical site infections (23.5%), continued progression of chronic limb ischemia (22.2%), and cardiac events (11.4%)(8). Additionally, nonadherence to medication regimens and follow-up appointments are common occurrences with CLTI patients (9).
A major challenge toward improving postoperative patient safety and outcomes in this patient population is that a large proportion of these issues—including 77% of postoperative wound infections(10)—occur post-discharge (11), where providers have little oversight. This issue is compounded by the multidisciplinary nature of CLTI care(12), involving various specialists and healthcare professionals (e.g., vascular surgeons, primary care providers, endocrinologists, skilled nursing facility personnel, physical therapists, home health nurses). Furthermore, 25% of CLTI readmissions occur at a different hospital from where the patient originally underwent surgery (13). This fragmented communication and uncoordinated care leads to poor patient safety due to challenges for vascular surgeons to fully understand all aspects that contribute to patients’ complications.
Altogether, the CLTI domain represents an area ripe for development of a post-discharge support intervention in order to improve patient safety and patient outcomes. We hypothesized that several of the common postoperative complications in this area are widely preventable or intervenable to stop progression (e.g., via wound care, medication adherence, and symptom monitoring). As a first step, we conducted a scoping review to identify known factors that were associated with post-discharge complications and patient safety events in this population.
Methods
We searched various electronic databases including PubMed and Google Scholar. The search was limited to articles discussing CLTI patients who had already undergone or were planned to undergo surgical intervention. The following search terms and keywords were used in this search with the appropriate Boolean operators: “chronic limb-threatening ischemia,” or “critical limb ischemia,” and “complications,” or “outcomes,” or “mortality,” or “readmission,” or “hospitalization,” or “rehospitalization,” and “predict,” or “predictors.” Additionally, the terms “surgery,” or “revascularization,” or “bypass,” or “procedure,” and “infection,” or “bleeding,” or “cardiac,” were included in later database searches.
The screening process involved reviewing the title, abstract, and full text when applicable to determine whether studies met inclusion criteria. Articles were excluded if they were not related to the predictors of outcomes and complications for CTLI patients undergoing surgical intervention. Additionally, studies were excluded if they were not available in English.
We systematically extracted data on the study methods, sample size, sample type, surgery type (e.g., bypass, amputation, endovascular revascularization, etc.), outcomes examined, predictors of outcomes examined, and overall findings.
Results
The initial search yielded a total of 3,879 studies. After screening, 27 studies remained, with
1,747,725 patients in total. The most examined postprocedural CLTI patient safety outcomes were mortality (k=10, 37%), limb loss (k=9, 33%), and readmission (k=4, 15%).
The most commonly identified predictors of mortality and limb loss in this population were medical comorbidities (k=6), particularly diabetes mellitus (k=2) and heart disease (k=2). Additional factors including wound severity (k=2) and malnourishment or frailty (k=2) were also found to be positively associated with these poor outcomes. Readmission was most associated with patients ≥65 years old (k=2) and females (k=2). Various comorbidities attributed to readmission including coronary artery disease, heart failure, diabetes mellitus, chronic kidney disease, ulcers or gangrene, anemia, obesity, and prior amputation (k=1). Additionally, perioperative events such as major bleeding (k=1), sepsis (k=1), and acute myocardial infarction (k=1) were predictors of readmission for CLTI patients. Patients’ travel time to the hospital was positively associated with readmission (k=1). Wound complications were positively predicted by surgical or hybrid modalities for revascularization (k=1). Infections were positively predicted by preoperative length of stay (k=1) and history of endovascular procedures (k=1).
Alternatively, postprocedural dual-antiplatelet therapy (k=1), surgical modalities for patients with great saphenous vein access (k=1), and endovascular modalities in malnourished patients (k=1) were found to have an inverse relationship with patient safety outcomes. Modality choice for revascularization did not significantly predict readmission (k=1). Private insurance status was found to a have negative correlation with readmission (k=1).
Discussion
Overall, comorbidities were the most commonly noted predictors of poor patient safety outcomes for CLTI patients post-surgical intervention, including mortality, limb loss, and readmission. Towards the development of a post-discharge intervention to improve patient safety in this patient population, this scoping review identified some characteristics of the population to consider focusing such an intervention on, including patients with comorbidities (particularly diabetes and heart disease), those with severe surgical wounds, those who are malnourished or frail, patients ≥65 years old, and females. However, there is little consistency in the relationships studied within the current literature and thus it was challenging to identify specific patterns and themes of outcomes and complications for CLTI patients. Additionally, there seems to be a lack of literature addressing the impact of the social determinants of health on outcomes for CLTI patients. Factors such as rurality of residency and degree of caregiver support may have significant implications in the overall care of patients but are currently understudied in regards to CLTI. The sparse literature base in these areas complicates the effort to determine the most effective intervention to target this problem.
As such, future research should continue to establish patterns amongst the various complications and negative outcomes experienced by CLTI patients. There should also be an increased focus on the social aspect of care for CLTI patients. Collecting such data may help better identify potential points of intervention to prevent further harm and improve patient outcomes. Toward this goal, our future work will continue to examine these issues via additional methods, including surveying physicians, patients, and developing machine learning models to examine outcomes with electronic health record (EHR) data.
Event Type
Poster Presentation
TimeTuesday, March 264:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives