ABSTRACT
Aims:
To determine the rate and patterns of unplanned 30-day readmissions (ReAd), compare readmission rates and examine the readmission trends in the context of quality-of-care measure assessment in pediatric surgery.
Methods:
A retrospective cohort study was conducted at a tertiary pediatric surgical center in Western India over a 3-year period. Children aged ≤18 years readmitted within 30 days of discharge following an elective or emergency surgical admission requiring an overnight stay were included and categorized in Group A and Group B, respectively. Data on demographics, index diagnosis, surgical procedures, comorbidities, postoperative complications, wound class, and management during readmission were analyzed.
Results:
Among 5230 pediatric surgical admissions, 56 unplanned readmissions were identified (readmission rate 1.07%). Readmissions were significantly higher following emergency admissions than elective procedures (3.1% vs. 0.6%; P < 0.000001). Gastrointestinal, colorectal, neurosurgical, and hepatobiliary procedures accounted for most readmissions. Nearly half of the readmitted patients required further surgical intervention, with no statistical difference between the two groups. Postoperative complication severity and wound class during the index admission were not significantly associated with operative management during readmission. Most readmissions were due to disease-specific factors, including Hirschsprung-associated enterocolitis, cholangitis following Kasai portoenterostomy, and ventriculoperitoneal shunt malfunction.
Conclusions:
Unplanned pediatric surgical readmissions in our setting were low (1.07%) and comparable with the international literature. Readmissions were driven mostly by emergency presentations and disease biology rather than by perioperative factors, supporting a cautious interpretation of readmission metrics as tools for quality improvement rather than standalone indicators of care quality.
KEYWORDS: Pediatric surgery, thirty-day readmissions, quality of care, ReAd, readmission, unplanned readmission
INTRODUCTION
Thirty-day readmission (ReAd) refers to an overnight stay within 30 days of an elective or emergency surgical procedure.[1] This is also considered one of the indicators of quality care by the UK National Health Service Care Quality Commission. This approach is grounded in the belief that an increased number of unplanned readmissions could signal the potential issues with care quality and safety.[1]
Unplanned readmissions are a considerable source of emotional and financial strain on patients and their families. It is a marker for assessing the quality of care and helps prioritize resource allocation.[2,3,4] Some strategies can be used in surgery to reduce this phenomenon.[5] The first UK report, from 2016, focused on readmissions at a tertiary pediatric surgical setting.[6]
Patients who are discharged from the hospital against medical advice are more likely to be readmitted early. This is often the case with bounce-back readmissions, in which patients return within a day of discharge.[7] In the United States, the Children’s Health Insurance Program Reauthorization Act initiated the Pediatric Quality Measures Program. As pediatric readmission rates are expected to serve as a quality metric tool, several jurisdictions have implemented penalties for readmissions as part of this initiative.[8,9,10]
The issue of surgical readmissions is a complex phenomenon encompassing both planned and unplanned events that may or may not be directly related to the primary surgical procedure. Various studies in the adult population have sought to identify the factors contributing to readmissions after a wide range of surgical procedures.[5,11,12,13,14,15,16,17,18,19,20]
While unplanned readmissions have been evaluated as a quality-of-care indicator in adult surgical populations in India, there is a paucity of published data examining 30-day ReAds specifically in pediatric surgical patients. To our knowledge, this study is among the first comprehensive examinations of unplanned readmissions following pediatric surgical admissions in an Indian tertiary-care setting.
This study aimed to determine the rate of unplanned 30-day readmissions following pediatric surgical admissions at a tertiary care center in Western India, compare readmission rates between elective and emergency cohorts, and describe the factors responsible, diagnoses, procedures, and management strategies associated with readmissions.
METHODS
The Hospital Information System (HIS) was utilized to identify all pediatric surgery readmissions at a tertiary care institution that provides comprehensive adult and pediatric specialty services. The study period spanned from June 2022 to May 2025. Approval for the study was obtained from the Institutional Ethics Committee. Children aged ≤18 years who underwent surgery either as an inpatient or as a day care case and were readmitted within 30 days of discharge were included. Readmission was defined as an unplanned return requiring at least one overnight hospital stay.[1] Patients discharged directly from the emergency department without admission were excluded, as were scheduled or planned readmissions. Oncology patients were also excluded, as their readmissions were frequently attributable to recurrent episodes of febrile neutropenia.
The primary outcome measures were the incidence of ReAd within 30 days after discharge, while the secondary outcome measures were the nature of primary admission (elective/emergency), primary diagnosis, comorbidities, length of hospitalization, class of wound, grade of complications during primary surgery, and need of intervention during ReAd.
For comparative analysis, patients were categorized according to whether their index admission was elective (Group A) or emergency (Group B), and outcome measures were evaluated between the groups.
Demographic and clinical variables extracted from the HIS included age, sex, mode of primary admission (elective or emergency), primary diagnosis, comorbidities, surgical procedures performed, and duration of initial hospitalization. Postoperative complications during the index admission were classified using the Clavien–Dindo system.[21] For the analysis, complications were grouped into low-grade (Grades I–II) and high-grade (Grades III–V) categories, in keeping with standard surgical reporting practices. Surgical wounds were graded according to Centers for Disease Control and Prevention (CDC) criteria and dichotomized into low-risk (clean and clean-contaminated) and high-risk (contaminated and dirty/infected) groups.
Readmission-related data included the date of readmission, working diagnosis, management strategy (conservative or surgical), procedures undertaken during readmission, clinical course, including perioperative complications, and length of hospital stay.
Statistical analysis
Statistical analyses were performed using the IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA). The continuous variables were summarized as means and medians, as appropriate, whereas categorical variables were reported as frequencies and percentages. Quantitative variables were compared using the Student t-test and categorical variables were compared using the Chi-square test. P ≤ 0.05 was considered statistically significant.
RESULTS
A total of 5,230 children were admitted during the study period. Of these, 4,259 (81.43%) admissions were elective, including day-case procedures, while 971 (18.57%) were emergency admissions. Fifty-six patients met the study’s inclusion criteria, yielding an overall readmission rate of 1.07%. This rate was comparable to that of previous studies, which reported ReAd rates of 0.9% and 2%, as described by Sinha et al.[6] and Mears et al.,[1] respectively. Twenty-six (46.4%) readmissions were following an electively planned procedure included in Group A, while the remaining 30 (53.6%) were readmitted after an emergency procedure included in Group B.
Among the readmitted cohort, 38 children (67.86%) were male and 18 (32.14%) were female. The median age at ReAd was 18 months (range: 1 day to 15 years). Comorbidities were present in 37.5% (21/56) of patients. Of all ReAd, 53.57% (30/56) occurred following an emergency primary admission, whereas 46.43% (26/56) followed an elective admission.
A total of 26 ReAd occurred among 4259 patients in Group A (elective cohort), compared with 30 among 971 patients in Group B (emergency cohort). ReAd rates were significantly higher in the emergency cohort compared to the elective cohort (3.1% vs. 0.6%). A two-proportion comparison demonstrated a highly significant difference (P < 0.000001). The relative risk of ReAd in emergency cases was 5.06 (95% confidence interval [CI], 3.02–8.47), indicating that emergency admissions had a fivefold higher risk of ReAd compared to elective cases. The length of stay at either the first or ReAd stay was not statistically significant between the emergency and elective cohorts (P = 0.23 and 0.81, respectively). 46.43% (26) of our entire cohort were managed conservatively during readmissions. Moreover, there was no significant difference in the need for additional surgery during ReAd or in the interval between discharge and readmission between the two groups [Table 1]. Appendicitis, hydrocephalus, and Hirschsprung’s disease-related procedures were the most frequent contributors, each accounting for 12.5% of ReAd. Together, gastrointestinal and colorectal conditions constitute the largest proportion of readmissions, followed by urological and neurosurgical procedures. Hepatobiliary conditions, particularly extrahepatic biliary atresia (EHBA), also represented a significant subset. This pattern highlights the predominance of abdominal and congenital conditions among children requiring early ReAd following surgical care [Table 2].
Table 1.
Comparison of elective and emergency readmission cohorts
| Parameter | Group A elective readmissions (n=26) | Group B emergency readmissions (n=30) | P value |
|---|---|---|---|
| Proportion of total readmissions, n (%) | 26 (46.4) | 30 (53.6) | - |
| Readmission rate, n/N (%) | 26/4259* (0.61) | 30/971† (3.09) | <0.000001 |
| Sex (male/female) | 16/10 | 22/8 | 0.51 |
| Median age, months (range) | 30 (2 months to 15 years) | 15.5 (1 day to 15 years) | 0.37 |
| Length of stay during index admission, mean (days) | 10.3 | 10.0 | 0.23 |
| Length of stay during readmission, mean (days) | 9.9 | 9.2 | 0.81 |
| Interval between discharge and readmission, mean (days) | 10.3 | 9.5 | 0.77 |
| Presence of comorbidity, n (%) | 11 (42.3) | 10 (33.3) | 0.68 |
| Further surgical intervention during readmission, n (%) | 13 (50.0) | 17 (56.7) | 0.82 |
*Total number of elective admissions during the audit period, †Total number of emergency admissions during the audit period
Table 2.
Spectrum of index diagnoses associated with unplanned 30-days readmissions (n=56)
| Index diagnosis/surgical category | Number of readmissions (%) |
|---|---|
| Appendicitis (including complicated cases) | 7 (12.5) |
| Hydrocephalus (VP shunt–related procedures) | 7 (12.5) |
| HD–related procedures* | 7 (12.5) |
| Urological procedures† | 6 (10.7) |
| Intestinal obstruction–related conditions‡ | 6 (10.7) |
| Anorectal malformations (including cloaca) | 6 (10.7) |
| Extrahepatic biliary atresia (Kasai-related) | 5 (8.9) |
| Other gastrointestinal conditions§ | 5 (8.9) |
| Choledochal cyst | 2 (3.6) |
| Blunt abdominal trauma | 2 (3.6) |
| Neural tube defects | 2 (3.6) |
| CDH | 1 (1.8) |
*Pull-through procedures and stoma closures, †Includes PUV, antenatal hydronephrosis, and hypospadias, ‡Intussusception, adhesive obstruction, tuberculosis, Meckel’s diverticulum, GOO, §Gastroschisis, GERD, IHPS, pilonidal sinus. VP: Ventriculoperitoneal, PUV: Posterior urethral valves, GERD: Gastroesophageal reflux disease, IHPS: Infantile hypertrophic pyloric stenosis, CDH: Congenital diaphragmatic hernia, GOO: Gastric outlet obstruction, HD: Hirschsprung’s disease
In the Group A (elective cohort), most of the readmissions (50%) were related to gastrointestinal surgeries encompassing Hirschsprung’s disease, anorectal Malformations, tuberculosis, and other abdominal diseases. 26.9% of cases were related to hepatobiliary procedures (EHBA, CDC) followed by 15.4% urological procedures. Similarly, in Group B (emergency cohort), the majority of readmissions (60%) were related to abdominal procedures, including gastrointestinal surgeries and congenital anomalies requiring abdominal procedures. Nearly 26.7% of cases involved neurological procedures, particularly those related to hydrocephalus and myelomeningocele, while the remaining readmissions were related to urological and hepatobiliary procedures [Table 3]. Analysis of perioperative severity markers [Table 4] revealed no significant association between complication severity (P = 0.31) or wound contamination status (P = 1.00) at the index admission and subsequent management during ReAd. Please refer to Supplementary Tables 1 and 2, which summarize the demographic profile, procedures during index admission, reasons for ReAd, and subsequent management of patients in both the elective and emergency cohorts.
Table 3.
Distribution of readmissions by surgical specialty
| Surgical specialty | Group A elective readmissions (n=26), n (%) | Group B emergency readmissions (n=30), n (%) |
|---|---|---|
| Gastrointestinal surgery | 13 (50.0)* | 18 (60.0)† |
| Neurosurgery | 1 (3.8) | 8 (26.7) |
| Hepatobiliary | 7 (26.9) | 2 (6.7) |
| Urology | 4 (15.4) | 2 (6.7) |
| Thoracic | 1 (3.8) | - |
*Gastrointestinal surgery includes gastrointestinal procedures (n=5) and congenital anomalies such as HD and anorectal malformations (n=8), †Gastrointestinal surgery includes gastrointestinal procedures (n=11) and congenital anomalies requiring abdominal procedures (n=7). HD: Hirschsprung’s disease
Table 4.
Association of perioperative factors with need for surgical intervention during readmission
| Variable (index admission) | Category | Conservative, n (%) | Surgical, n (%) | P |
|---|---|---|---|---|
| Clavien–Dindo class | Low-grade (I–II) | 23 (50.0) | 23 (50.0) | 0.31 |
| High-grade (III–V) | 3 (30.0) | 7 (70.0) | ||
| Wound class | Low-risk (clean + clean-contaminated) | 23 (46.9) | 26 (53.1) | 1.00 |
| High-risk (contaminated + dirty) | 3 (42.9) | 4 (57.1) |
Supplementary Table 1.
Diagnosis at readmission and management in the elective cohort
| Age | Sex | Elective procedure | Reason for readmission | Management |
|---|---|---|---|---|
| 4 months | Female | IOC and open Kasai Portoenterostomy | Cholangitis | Conservative |
| 9 years | Male | Cystoscopy and PUV fulguration | UTI with urinary retention | Cystoscopy with valve fulguration |
| 15 months | Male | TIP urethroplasty | UCF with Glanular dehiscence | Conservative |
| 3 years | Male | EUA with anal dilatation with biopsy from proximal stoma site with stoma closure | Urinary retention, HAEC | Adynamic segment RA and transverse colostomy |
| 15 years | Female | Laparoscopic Nissen’s floppy fundoplication | Child tolerating only liquids. Vomiting after solid meals | Diagnostic lap and loosening of fundoplication wrap under endoscopy guidance |
| 5 years | Male | EUA, dilatation of the rectal anastomosis and Colostomy closure | Enterocutaneous fistula | Exploratory laparotomy + adhesiolysis and DIvided end colostomy |
| 15 years | Male | Ileostomy closure | SAIO | Conservative |
| 10 years | Male | UC fistula repair | Urinary retention | SPC insertion |
| 6 years | Male | Sinus tract excision + Laminectomy + Dermoid cyst marsupialisation | Bleeding from Wound site | Local exploration |
| 4 years | Male | DL with resection and anastomosis of meckel’s bearing segment of ileum | Ileus with vomiting | Conservative |
| 12 years | Male | Left Ureterostomy closure with DJ stent insertion | UTI | Conservative |
| 11 months | Male | Laparoscopic assisted Swenson’s pull through (Sigmoid colon loop stoma pull through) | SSI and port site hernia with SAIO | Port site hernia repair with Secondary Suturing of Wound |
| 5 months | Male | Portoenterostomy | Sepsis and multiorgan dysfunction syndrome | Conservative |
| 3 months | Female | PSARP | Wound Dehiscence | Secondary suturing |
| 5 months | Female | ASARP | Perineal wound dehiscence | EUA with anal dilation and secondary (tension) suturing |
| 2 years | Female | Laparoscopy asssited mobilisation of distal stomal loop, excision of stenotic segment with fistula tract and proximal stomal pull through | Retrorectal collection | Incision and Drainage |
| 8 years | Male | Laparoscopy assisted primary Swenson procedure | HAEC | Conservative |
| 8 years | Male | Laparoscopic assisted Primary Swensons pull through | Dehiscence of colo anal anastomosis | EUA and right transverse colostomy |
| 13 years | Female | Pilonidal sinus excision and Limberg flap | SSI and Wound gape | Conservative |
| 9 years | Female | Laparoscopic CDC excision + Hepaticoduodenostomy | Indigestion | Conservative |
| 1 year | Female | Colostomy Closure | SSI with wide wound gape | Secondary suturing |
| 3 months | Male | Thoracoscopy converted to right open posterolateral thoracotomy with CDH repair | Right lung collapse with pneumothorax | Needle thoracocentesis |
| 2 months | Female | Exploratory laparotomy, IOC, Kasai procedure, and liver biopsy | Cholangitis | Conservative |
| 2 months | Male | IOC + Kasai Portoenterostomy | Cholangitis | Conservative |
| 2 months | Male | Kasai Portoenterostomy | Cholangitis | Conservative |
| 3 months | Female | Kasai Portoenterostomy | Cholangitis | Conservative |
PUV: Posterior urethral valves, IOC: Intraoperative cholangiogram, CDH: Congenital diaphragmatic hernia, HAEC: Hirschsprung’s associated enterocolitis, SSI: Surgical site infection, EUA: Examination Under Anesthesia, PSARP: Posterior sagittal anorectoplasty, ASARP: Anterior sagittal anorectoplasty, UTI: Urinary tract infection, SAIO: Sub-acute intestinal obstruction, UC: Ulcerative colitis, RA: Right anterior, TIP: Tubularized incised plate, UCF: Urethrocutaneous fistula, SPC: Suprapubic catheter, DL: Diagnostic laparoscopy
Supplementary Table 2.
Diagnosis at readmission and management in the emergency cohort
| Age | Sex | Emergency procedure | Reason for readmission | Management |
|---|---|---|---|---|
| 4 years | Female | Stoma closure | SAIO | Conservative |
| 5 years | Male | Laparoscopic appendectomy | SAIO/ileus (no air fluid levels) | Lap converted to open adhesiolysis |
| 11 years | Male | Laparoscopic appendectomy + USG guided abscess aspiration | SAIO | Conservative |
| 1 days | Male | Gastroschisis repair (ventral hernia creation) | SAIO | Conservative |
| 14 years | Male | DL + adhesiolysis + drainage of intraabdominal bilious collection | Recurrence of abdominal pain with residual bile collection | Conservative |
| 14 years | Male | DL and abdominal wall repair | Grade III Liver injury with biliary leak s/p DL | DL + adhesiolysis + drainage of intraabdominal bilious collection |
| 1 month | Male | Ileostomy | Intestinal obstruction | Diagnostic lap and adhesiolysis folllowed by exploratory laparotomy and R/A with end colostomy |
| 1 year | Female | VP shunt removal | Persistent CSF leak from wound site with swelling | Left VP shunt insertion |
| 5 years | Male | Laparoscopic appendectomy | Small bowel adhesive obstruction | Open adhesiolysis |
| 13 months | Male | Cystoscopic right DJ stent insertion | UTI | Conservative |
| 18 months | Male | DL and mesenteric lymph node biopsy | Umbilical port site hernia | Umbilical hernia repair |
| 10 months | Male | Cystoscopy with RGU with Supra pubic Catherisation | SPC blocked and misplaced | Open Re SPC insertion |
| 5 days | Female | Exploratory laparotomy and loop ileostomy | Severe peristomal excoriations | Conservative |
| 15 years | Male | Exploratory laparotomy with adhesiolysis and drainage of abscess | Acute small bowel obstruction | Exploratory laparotomy +adhesiolysis |
| 3 months | Male | Right VP shunt insertion | Shunt displacement | Right EVD insertion |
| 54 days | Male | Ventral hernia creation for Gastroschisis | SAIO | Conservative |
| 18 months | Female | Laparoscopic appendectomy | o/c/c perforated appendicitis with adhesive intestinal obstruction | Laparoscopic adhesiolysis |
| 11 years | Male | Laparoscopic appendectomy | O/C/O acute perforated appendicitis with RIF collection | USG guided aspiration and pigtail insertion |
| 4 years | Male | Left sided VP shunt removal and left medium pressure VP shunt insertion | O/C/O postmeningitic Hydrocephalus s/p bilateral VP shunt with peritonitis | Conservative |
| 7 years | Male | Exploratory laparotomy + abdominal drain placement for Caustic ingestion associated GOO | Feed intolerance with vomiting with abdominal pain | Laparoscopy converted to exploratory laparotomy with gastrojejunostomy |
| 11 months | Male | Port site Hernia repair with secondary suturing of wound in a case of HD s/lap assisted swensons pull through | Adhesive SAIO | DL and exploratory laparotomy and adhesiolysis |
| 3 months | Male | Right medium pressure VP shunt insertion | Meningitis | Conservative |
| 2 months | Male | ETV converted to left sided medium pressure VP Shunt insertion | Signs of meningitis with swelling over shunt tract site | Left VP shunt removal f/b right VP shunt insertion |
| 5 months | Female | DL and release of adhesive band | Persistent vomiting (Jejunal stricture) | Exploratory laparotomy and resection and anastomosis of strictured segment |
| 2 years | Female | Lap assisted meckel’s diverticulectomy | SAIO | Conservative |
| 5 years | Male | Right VP shunt removal | Raised ICT symptoms | Left VP shunt insertion |
| 11 years | Male | Laparoscopic appendectomy | SAIO | Conservative |
| 1 month | Female | MMC excision and repair | Wound dehiscence | Conservative |
| 8 months | Female | Right VP shunt insertion | Displaced right sided VP Shunt | VP shunt removal |
| 22 days | Male | Laparoscopic pyloromyotomy | Gastroenteritis | Conservative |
VP: Ventriculoperitoneal, SAIO: Sub-acute intestinal obstruction, USG: Ultrasonography, R/A: Right/anterior, CSF: Cerebrospinal fluid, UTI: Urinary tract infection, RGU: Retrograde urethrography, SPC: Suprapubic catheter, EVD: External ventricular drain, RIF: Right iliac fossa, GOO: Gastric outlet obstruction, HD: Hirschsprung’s disease, ETV: Endoscopic third ventriculostomy, CMV: Cytomegalovirus, DL: Diagnostic laparoscopy, ICT: Intracranial tension, MMC: Myelomeningocele
DISCUSSION
In this retrospective cohort of 5230 pediatric surgical admissions at a tertiary center in Western India, we observed an overall 30-day unplanned ReAd rate of 1.07%, which is low and compares favorably with the international benchmarks. Large UK audits have reported readmission rates ranging from 0.9% to 2% in similar tertiary pediatric surgical settings,[1,6] while multi-institutional North American National Surgical Quality Improvement Program- Pediatric (NSQIP-P) reports describe unplanned readmission rates between 1.3% and 10.8% across pediatric surgical subspecialties.[22] In contrast, substantially higher rates have been reported in some Asian cohorts, such as the 9% readmission rate described by Zheng et al.[23] These comparisons place our findings within the lower range of reported pediatric surgical readmission rates globally.
Although such comparisons provide useful context, direct comparison between institutional studies and large international databases should be interpreted cautiously. The present study reflects the clinical spectrum of a tertiary referral center and includes both elective and emergency pediatric surgical admissions, whereas large registry-based analyses frequently examine the selected operative cohorts. These differences in patient population and data capture approaches may influence reported readmission rates and should be considered when interpreting the cross-study comparisons.
In our study, readmissions were significantly more frequent following emergency procedures than elective surgeries (3.1% vs. 0.6%; P < 0.000001). Emergency admissions were associated with a markedly increased risk of ReAd (relative risk, 5.06; 95% CI, 3.02–8.47), indicating a fivefold higher risk of readmission than elective admissions. This closely mirrors observations in UK audits and aligns with earlier analyses that defined emergency surgery as an independent risk factor for unplanned readmission.[1,6] Emergency presentations are often characterized by greater disease severity, higher physiological stress, and increased postoperative complication risk, thereby explaining the observed difference.[1,6]
In our cohort, the reasons for ReAd were largely disease and procedure-specific, with the most common indications being small bowel obstruction and or ileus, surgical site and wound-related complications, cholangitis following surgery for EHBA, Hirschsprung-associated enterocolitis (HAEC), colorectal surgery, and ventriculoperitoneal shunt-related complications. This pattern closely mirrors international literature, including NSQIP-P data,[22] which identifies surgical site infections as the prime cause of readmission, with UK and US studies[1,6,24] identifying postoperative infection, ileus, and abdominal pain as widely known triggers for return to hospital. Cholangitis following surgery for EHBA and shunt-related readmissions represents the expected pattern of recovery that differs by disease rather than failure in care perioperatively.[24]
Certain index procedures contributed disproportionately to the ReAd workload, including appendicectomy, colorectal procedures, stoma closures, ventriculoperitoneal shunt surgeries, and Kasai portoenterostomy. Surgery for appendicitis, in particular, has been consistently identified as a major contributor to readmissions in pediatric surgery. Similarly, VP shunt insertion procedure carries an inherent high risk of ReAd, a finding that is firmly supported by NSQIP-P analyses.[22]
Among both the elective and emergency cohorts (Groups A and B), almost half of the readmitted patients required further surgical intervention, commonly for adhesive obstruction, wound-related complications, port site hernias, shunt-related, and anastomosis-related issues. Adhesiolysis was the most commonly performed surgery during ReAd. This observation mirrors prior reports, including that by Sinha et al., which found that more than one-third of readmitted patients required additional surgery, underscoring the close association between postoperative complications and ReAd severity.[6]
A single UK center conducted sequential audit studies, which provided important context for interpreting these findings. In their initial audit, relatively low baseline readmission rates were driven by proactive discharge planning, supervision of a senior, clear and consistent communication with families, and timely access to postoperative surgical review. They further refined their practices, which included better written and verbal discharge advice, counseling by a nurse specialist, a formally assigned discharge coordinator, and dedicated counseling for stoma, wound, and device care, resulting in a further reduction in their readmissions, particularly related to superficial wound infections and device-related complications. Despite improvements across their sequential audits, the authors stated that a significant proportion of their readmissions remained unavoidable and warned against using readmission rates as a standalone marker of quality of care.[1,6]
The low rate of unplanned readmissions observed in this cohort likely reflects established institutional practices integrated into routine care. Patient management follows a structured, senior-supervised residency model that ensures the continuity of care and early recognition of postoperative issues. Discharge is undertaken only after clinical stability, adequate oral intake, and return of bladder and bowel function. Discharge summaries prepared by trainees are reviewed by senior clinicians, and counseling is reinforced by both medical and nursing staff, often in the local language. Active involvement of experienced nursing personnel in caregiver education further supports safe discharge. These measures, comparable to strategies reported in international audits, may explain the favorable readmission outcomes observed in this initial Indian study without targeted interventions.
Even though ReAd rate has been advocated as a quality-of-care indicator, its reliability in pediatric surgery remains a matter of ongoing debate. The validity of ReAd metrics in children has been questioned by Polites et al., underscoring their relatively low frequency and frequent association with complex, nonmodifiable patient and disease-related factors.[25] Similarly, Brown et al. stated that early pediatric ReAd were linked to underlying chronic medical conditions rather than a lack of index operative care in more than half of the patients.[26] Our findings closely resemble this evidence, as a significant proportion of readmissions were largely determined by disease biology, such as HAEC, cholangitis post-Kasai, and known ventriculoperitoneal shunt malfunctions, rather than deficiencies in perioperative or discharge-related care. From a preventability perspective, these conditions represent recognized postoperative disease trajectories, whereas only a smaller subset of readmissions – such as those related to wound complications or adhesive obstruction – may potentially be influenced by preventive strategies.
The large cohort size, inclusion of both elective and emergency admissions, and an elaborate case-level analysis of readmission indications and subsequent management are the key strengths of our study. However, several limitations necessitate the considerations. Some ReAd may have been missed if parents had presented to institutions other than ours after discharge. Excluding pediatric solid tumor patients further limits its generalizability across the full spectrum of pediatric surgical practice. Collectively, our findings add to the existing body of evidence that low readmission rates are often reflective of robust systems of care, rather than standalone perioperative factors. This study highlights the clinical characteristics of patients who are readmitted following elective and emergency pediatric surgeries. Future prospective studies comparing readmitted and nonreadmitted patients within similar disease cohorts, supported by multivariate analysis, may help identify the predictors of readmission and guide targeted strategies to further reduce readmission rates and improve the quality of care.
Future directions and recommendations
In future, we need to have a postdischarge provision of uniform, round-the-clock access to a dedicated pediatric surgical contact, enhanced parent education, universal, protocol based counseling for stoma care, instructions related to wound care and indwelling devices, development of a formal medical-surgical joint admission pathway for children with known associated comorbidities, early review and focused ER triage protocol for patients who underwent procedures associated with higher readmission risk along with strengthening of tele-consultation support and coordination with local healthcare providers. This may help reduce potentially avoidable readmissions, may improve coordinated care, facilitate timely intervention, and safe management of minor postoperative concerns closer to the patient’s residence. This, alongside long-term prospective and multicentric evaluation, will validate the sustainability and quality implications of low readmission rates.
CONCLUSIONS
The 30-day unplanned ReAds rate in our setting remains low and comparable to the leading international benchmarks. The patients operated upon in emergency developed postoperative complications, and those with inherently high-risk surgical conditions are more likely to have readmissions, many of which are driven by disease biology rather than deficiencies in perioperative care. Whereas incremental refinement of discharge processes and multidisciplinary coordinated effort may reduce avoidable readmissions, both prior to and our study highlight that unplanned readmissions are not always preventable. Readmission metrics should therefore be interpreted cautiously and used as tools for institutional reflection and targeted quality improvement, rather than as standalone indicators of quality of care in pediatric surgical practice.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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