Screening Pediatric Patients for Readmission Risk

Children's Mercy Kansas City Children's Mercy Kansas City

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Presentations

2019

Screening Pediatric Patients for Readmission Risk Screening Pediatric Patients for Readmission Risk

Sarah Bradshaw Children's Mercy Hospital, srbradshaw@cmh.edu

Blair Buenning Children's Mercy Hospital, bnbuenning@cmh.edu

Anita Powell Children's Mercy Hospital

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Recommended Citation Recommended Citation Bradshaw, Sarah; Buenning, Blair; and Powell, Anita, "Screening Pediatric Patients for Readmission Risk" (2019). Presentations. 24. https://scholarlyexchange.childrensmercy.org/presentations/24

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© The Children's Mercy Hospital 2017

Screening Pediatric Patients

for Readmission Risk

1

Sarah Bradshaw, MSN, RN, CPN, ACM-RN

Blair Buenning, MSN, RN, CPN, ACM-RN

Anita Powell, MA, BSN, RN, BC, ACM-RN

Experts in Pediatric Care

• Nearly 8,000 employees

• 750+ pediatric specialists

• 2,200 nurses

• 1,000+ allied health

professionals

• More than 900 volunteers

2

Our Locations

3

The Highest Level of

Care for Kids• 40+ pediatric specialty areas

• Highest level pediatric trauma center

• Highest level neonatal intensive care unit

• Ranked among the best children’s

hospitals in the country by US News

• Honored by the Magnet® Recognition

Program for excellence in nursing

• Leader in pediatric research & innovation

4

Hospital Acquired Conditions• Preventable Readmissions

• Central Line-Associated Blood Stream Infections (CLABSI)

• Catheter-Associated Urinary Tract Infections (CAUTI)

• Serious Falls

• Pressure Injury

• Surgical Site Infections

• Venous Thromboembolism

• Adverse Drug Events (ADE)

5

Pediatric Readmission Costs

• Cost per event1= $9,540

• Average yearly Medicaid claim for single complex patient = $69,906

• Nationwide annual cost (2015) = $1.5 Billion

6

Pediatric Readmission Costs

• Health Risk to Patients (HACs)

• Family Inconvenience

• Unnecessary use of hospital resources

7

Case Management Standard of Care

8

Screening/ Identification

Through use of identification criteria, stratify patients at risk

AssessmentExpand on knowledge gained by screen and complementary to other disciplines’ assessements

“Case management is expected to have a defined method for

screening/identification and assessment of patients in need of case

management services”

Screening for Readmission Risk

9

Adult Screen Tools

Modified LACE Tool

Pra Risk Tool

Cerner’s readmission stratification score

HOSPITAL Score

Pediatric Screen Tools

Why Develop a Screen tool?

DecreaseReadmissions

Length of Stay

Emergency Department visits

IncreasePatient/family satisfaction with care

Compliance with national standards of practice & CMS regulations

Literature Review

➢Identified pediatric risk factors

➢Developed tool based on findings

➢Validated need for tool to look at multiple

factors, not just admitting diagnosis

Identified Risk Factors

Admitting Diagnosis

Chronic Condition Indicator

Readmission History

Admission Acuity

Insurance

DME Home Nursing Home Therapy Language

Cycle of QI and ResearchIdentify

the Need

Literature Review

QI

ResearchEvaluation of Results

Formulate plan

Apply next steps

Gaps Addressed in QI Cycles

14

Validity

RELIABILITY of data

Evidence based practice

Lack of documentation/data points available

QI Project Measures

Outcome100% of admitted

patients will have a screen complete within 24 hours of admission

Process>85% reliability between

Care Managers

Decrease average completion time

100% of fields completed within each

entry

BalancingNurse Care Manager

satisfaction

30-day readmission rate

Identifying How To Change

1. What are we trying to accomplish?

2. How will we know that a change resulted

in improvement?

3. What change could we make that might

result in improvement?

Plan – Do – Study - Act

17

Implement Tool

Cycle 1

Decrease variability

Cycle 2Focus on

missed populations

Cycle 3

Modify tool

Cycle 4Sustain

results

Cycle 5

Final Control Chart

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Co

mp

leti

on

Rate

Time

HARRPS Tool Completion Rate within 24 Hours of Admission -Overall Data

Sustaining Improvements

Post QI Next Steps → Research

Produce and share

generalizable knowledge

Cross validate findings

Test HARRPS validity and predictive ability in

identifying pediatric

readmission risk

Obtain Institutional

Review Board (IRB) Approval

HARRPS Tool

21

Research Overview

Evaluate

Evaluate each category of tool for validity and reliability

Associate

Associate scores based on statistical findings

Combine

Combine scores to produce a total

Identify

Identify high, moderate, and low risk scores

Validate

Cross validate findings

Identified Risk Factors

Admitting Diagnosis

Chronic Condition Indicator

Readmission History

Admission Acuity

Insurance

DME Home Nursing Home Therapy Language

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

PR

EV

AL

EN

CE

Admission Diagnosis

Control Group 30-Day Readmission

<0.0001 <0.0001

* p-value

0%

10%

20%

30%

40%

50%

60%

0 1 2 3 4+

PR

EV

AL

EN

CE

Chronic Condition Indicator

Control Group 30-Day Readmission

* p-value

<0.0001 0.3517 <0.0001 <0.0001 <0.0001

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Readmitted within 30 days Inpatient Admit in last 6 months

PR

EV

AL

EN

CE

Readmission History

Control Group 30-Day Readmission

* p-value

<0.0001 <0.0001

0%

10%

20%

30%

40%

50%

60%

70%

80%

ICN/PICU Admission Significantpsychosocial concern

Medical transport fromoutside facility

No admission acuityidentified

PR

EV

AL

EN

CE

Admission Acuity

Control Group 30-Day Readmission

* p-value

<0.0001 0.1118 0.1971 <0.0001

0%

10%

20%

30%

40%

50%

60%

70%

Self Pay Medicaid Commercial/Private

PR

EV

AL

EN

CE

Insurance Type

Control Group 30-Day Readmission

* p-value

0.4303 <0.0001 <0.0001

0%

2%

4%

6%

8%

10%

12%

14%

1 2 3 4+

PR

EV

AL

EN

CE

Medical Equipment Count

Control Group 30-Day Readmission

* p-value

0.163 <0.0001 <0.0001 <0.0001

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Private Duty Nursing Skilled Nursing

PR

EV

AL

EN

CE

Home Nursing

Control Group 30-Day Readmission

* p-value

<0.0001 <0.0001

0%

1%

2%

3%

4%

5%

6%

Home Occupational Therapy Home Physical Therapy Home Speech Therapy

PR

EV

AL

EN

CE

Home Therapy

Control Group 30-Day Readmission

* p-value

<0.0001 <0.0001 <0.0001

Caregiver Language

Associate Scores

1Admitting Diagnosis

3Chronic Condition

Indicator

2Readmission

History

1Admission Acuity

1Insurance

4DME

1Home Nursing

1Home Therapy

0Language

Identify High Risk Score

Identify Risk Score Cut PointsRisk score 14: Excluded from analysis due to only

having 4 out of 5371 samples

Cross Validate Findings

C-Statistic Score compared to

Adult Risk Tools

HARRPS

0.68

Modified

LACE

0.63

Cerner’s

Adult

readmission

calculation

0.69

Pra Risk

Tool

0.65

HOSPTIAL

Score

0.76

Timeline

Investigation of current risk tools

Literature Reviews & Initial Build

Quality Improvement Project

Research Project

Data Review and Tool Finalization

Tool Dissemination

Fall

2015

Spring

2016

Fall

2016

May 2017-

June 2018

Summer

2018

2019 &

Beyond

Future Implications

What innovative opportunities do we have at Children's Mercy, and through SPS to utilize HARRPS Tool

readmission risk findings?

Questions? Please contact HARRPS@CMH.edu