Reducing Length of Stay and Hospital Readmission for Orthopedic Patients: A Quality Improvement Project

BackgroundTransitioning patients from the hospital to home after a total hip or knee arthroplasty is challenging. Severe pain, comorbidities and complex medication regimes have the potential to delay readiness for discharge, increase length of stay (LOS), and cause readmissions.ObjectiveThe goal of this practice improvement project was to improve patient readiness for discharge after total joint arthroplasty to reduce LOS, prevent emergency department (ED) visits, and prevent hospital readmissions.MethodsThis quality improvement project was guided by the Iowa Model and implemented a prepost program implementation evaluation design. Nurses incorporated the Registered Nurse Assessment of Readiness for Hospital Discharge Scale (RN-RHDS) to guide and evaluate discharge education efforts.ResultsThe focused education cohort demonstrated significantly decreased LOS and decreased readmissions compared to the cohort receiving standard education efforts. ED visits were not significantly different amongst cohorts.ConclusionThis practice improvement project demonstrates successful translation of research into practice.Implications for NursingThe use of focused education and the RN-RHDS tool is recommended for nursing to improve patient readiness for discharge and patient outcomes.

Lessons Learned by Medical Students about Systems-Based Practice as Patients Transition their Care

Background: One in five patients suffer an adverse event within two weeks of discharge as they transition from one healthcare setting to another. Systems-based practice is a core competency of physicians and seeks to minimize these events; however, education of trainees is inconsistent. We asked whether structured post-discharge phone calls and reflections on barriers to discharge and practice improvement can enhance students’ understanding of systems-based practice. Method: Medical students in the Internal Medicine Clerkship were assigned to perform a structured post-discharge phone call on hospitalized patients as part of a “Transitions of Care” assignment. Students reflected on issues occurring at the transition from hospitalization to discharge. We performed qualitative analysis of 90 medical student responses and identified themes and sub-themes addressing issues with care transitions. Results: Students consistently identified barriers to safe discharge including issues scheduling follow-up care, poor care coordination, and inadequate social support. The post-discharge phone calls revealed problems with patients’ understanding of their discharge diagnosis, medication-related issues and patients’ failure to attend scheduled follow-up. Common student-proposed practice improvement interventions included: enhanced provider-patient communication and education, improved interdisciplinary collaboration and care coordination, and greater attention to patient’s psychosocial and financial status. Conclusions: Medical students learned about systems-based practice from a transitions of care assignment involving a post-discharge phone call, identifying critical events in over half of patients identified. Self-reflective practice within the context of direct patient care offers insights into practice improvement in care transitions.

Practice Improvement Projects in an Interdisciplinary Palliative Care Training Program

Context: Demand for palliative care (PC) continues to increase with an insufficient number of specialists to meet the need. This requires implementation of training curricula to expand the workforce of interdisciplinary clinicians who care for persons with serious illness. Objectives: To evaluate the impact of utilizing individual practice improvement projects (PIP) as part of a longitudinal PC curriculum, the Coleman Palliative Medicine Training Program (CPMTP-2). Methods: Participants developed their PIPs based on their institutional needs and through a mentor, and participated in monthly meetings and bi-annual conferences, thereby allowing for continued process improvement and feedback. Results: Thirty-seven interdisciplinary participants implemented 30 PIPs encompassing 7 themes: (1) staff education; (2) care quality and processes; (3) access to care; (4) documentation of care delivered; (5) new program development; (6) assessing gaps in care/patient needs; and (7) patient/family education. The majority of projects did achieve completion, with 16 of 30 projects reportedly being sustained several months after conclusion of the required training period. Qualitative feedback regarding mentors’ expertise and availability was uniformly positive. Conclusion: The CPMTP-2 demonstrates the positive impact of PIPs in the development of skills for interdisciplinary learners as part of a longitudinal training program in primary PC. Participation in a PIP with administrative support may lead to operational improvement within PC teams.

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study (Preprint)

BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS We divided our study into 4 phases—phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post–CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post–CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre–CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.