“Eliminating preventable readmissions and mortality is our focus,” he said. “It will take everyone’s efforts to reach the goal.”
Reaching Out Post Discharge
While not every situation leading to a readmission can be controlled, eg, the impact of patient demographics, some can be resolved before they bring the patient back to the hospital.
Working in partnership with an interdisciplinary team from both the in- and outpatient sides of cardiac care, the CICU developed a program to follow up with patients most at risk for readmission. This included those admitted for heart failure, with chest pain, for a cardiac intervention or with a VAD.
Nurses called patients 48 hours after their discharge and then once a week for three weeks, asking key questions, eg, Do you have any complications? Are you able to get your medications? Do you understand your medications? “We specifically wanted clinical nurses with cardiac experience to make the calls because they are better able to answer patients’ disease-specific questions and they already have a relationship with the clinical provider,” said Leah Moran, MSN, nurse manager.
The results have been impressive. Since program began in September, the unit’s 30-day all-cause readmission rate for heart failure has fallen by 35 percent. In fact, “we’ve had only two 7-day readmissions since starting the program.”
A similar initiative in neurosurgery has also made a positive impact on readmissions as well as after-hours calls for patients undergoing an elective procedure. As part of this program, patients received a call within two business days of discharge fromeither a nurse practitioner or physician’s assistant, which was documented in EPIC. Readmission rates for patients receiving follow-up phone calls were lower than those who did not receive a call, as were the number of after-hours calls received by residents.
Taking the right medication at the right time and understanding why this is important are key to preventing complications and, possibly, readmissions. This is especially true for patients with complex medical needs requiring multiple medications. To help ensure that patients received the necessary information about medications, Ravdin 6 created a “medication minute” initiative. “Our goals were to help staff nurses become more confident in talking to their patients about medications as well as ensure that consistent information was being delivered,” said Joe Kluck, Pharm.D., the unit’s clinical pharmacist. Kluck worked with Marie Fisher, MSN, nurse manager, who facilitated the collaboration between pharmacy and nursing.
Kluck initially created brief scripts focusing on the indications and side effects for the 12 most used meds used on the unit. In short morning huddles with nurses, he delivered the information. Each week a new medication minute took place, gradually expanding to include additional medications. He also emails the information to nurses on night shifts to ensure consistency.
The results have been significant. Since implementing the medication minutes, the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores addressing communication regarding medications demonstrated a nearly 50% improvement in the last quarter of the fiscal year 2012. “Ravdin 6 continues to aim for improved communication regarding medications and also continues to monitor how these efforts impact HCAHPS results,” Kluck said.
These initiatives were just a sampling of the many efforts throughout UPHS to help reach our goal. (See sidebar below for additional initiatives). “I thank you for all you’ve done but we cannot rest on our laurels,” Brennan said. “There’s still a great deal to do.”
Steps to Bring Us Closer to Our Goals
Several initiatives throughout the Health System are helping us move closer to our goal of eliminating preventable readmissions and mortality, including:
- Clinical Decision Support: Using an Early Warning System to identify patients who are at increased risk of developing sepsis and to notify the covering provider and nurse, and nurse coordinator of a potential problem.
- Primary Care Connector Nurse: Improving the discharge process for patients in the Penn Medical Home Practices, focusing on communication and patient preparedness.
- PCAH-Penn E-lert Partnership: Using Penn e-lert critical care telehealth staff to monitor vital signs of Penn Care at Home patients and alerting covering physician and visiting nurse of any problems.
- YORN (Your Opinion Right Now): Gathering real-time patient feedback to improve in-patient experience and increase patient engagement.
To learn more, go to the CEQI website and click on ‘500-day event at HUP.’