This article first appeared on Wing of Zock (http://wingofzock.org) on March 15, 2013.
By Jason Lightbody
It’s easy to say we need to reduce readmission rates, but the real question is, How do we do it? With changes to Medicare reimbursements looming, it’s increasingly important for institutions to do their best to improve patient recovery rates after discharge. During the past year, Montefiore Medical Center’s Performance Improvement Committee for the Department of Cardiovascular and Thoracic Surgery began work on an expansive project to reduce readmissions of heart surgery patients.
The GRRAM Project (Goal to Reduce ReAdmissions at Montefiore) outlined three goals to understand and impact heart surgery readmissions. We began by analyzing why patients were being readmitted.
The analysis was conducted over six months. Some of the key findings were:
- Most patients were readmitted within 15 days of discharge.
- Most common symptoms for readmission were shortness of breath, chest pain, congestive heart failure, and volume overload.
- Majority of readmissions were from home, not rehab.
- Patients don’t call to ask questions; they go to the emergency department instead.
Based on this information, the committee developed a few simple initiatives to improve patient understanding and behaviors. All heart surgery patients are now discharged with an increased dose of diuretic and pain medication, unless contraindications exist. This aims to reduce readmissions for volume overload that requires extra diuresis. The pain medication increase is to limit readmissions due to incisional chest pain.
Patients reported that they either don’t know to call, are afraid to call or just don’t think to call and ask questions. Now, at discharge, patients receive a bracelet that clearly lists the department’s 24-hour call center phone number. There is an on-call team to answer the phone and address patient questions at all times. Patients report that they find this reassuring and extremely helpful.
One of the most important elements of the GRRAM Project is the Cardiothoracic Surgery Early Post-Op Clinic, which is run by nurse practitioners (NPs). All patients are sent home from the hospital with an appointment to see an NP within 7 to 10 days of discharge. The appointment’s goal is to resolve any issues before readmission occurs and to provide education that may have been missed at discharge, such as cleaning the incision, the importance of diet, and the need to walk. It can also serve to determine if a readmission is necessary at that point in time.
Data analysis of the GRRAM Project will begin in a few months, but the committee is optimistic about outcomes and already has seen great progress. We owe it to our patients, the community, and the hospital to do our best to maintain the highest level of quality care.
—Jason Lightbody is a senior physician assistant and GRRAM Project coordinator, Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center.