Working Toward Decreased Readmissionsin the Pediatric GI Population

Holly Bernal, RN, MSN, NP, IBCLCMary L. Johnson Ambulatory Care Center

Pediatric GastroenterologyClinic Coordinator

The PICO QuestionWould pediatric GI multidisciplinary team members, after implementation of education of the Ohio Children’s Hospital for Patient Safety recommendations on readmissions have improved knowledge related to readmissions?

The Aim• To look at reasons for readmission and repeat clinic appointments for

pediatric gastroenterology patients

• To improve understanding of the Ohio Project Bundle on readmissions and how we can use that in the clinic setting

• To make recommendations that could improve patient care, decrease readmissions and unnecessary repeat clinic appointments

Background

• Educating the residents on preventable readmissions proved beneficial. 98% of those who attended the multidisciplinary readmissions meeting felt more involved in trying to improve the readmission rate compared to 40% of those who did not attend the meeting. Njeim et al. (2012)

Background

• Factors contributing to potentially preventable readmissions included care during the stay (57%), the discharge process (67%) and follow up care (79%). Figenbaum et al. (2012)

• In a study of 782 adult patients with heart failure, 68% of the patients that received all their discharge instructions were significantly less likely to be readmitted for any cause (p = 0.003) and for heart failure (p=0.035) than those who did not receive complete discharge instruction. VanSuch et al. (2006)

Background

Current Practice

• Patients are scheduled based on the providers determination for follow up and if the patient calls asking to be seen.

• There is no current protocol at LPCH for decreasing readmissions, but LPCH is implementing the Ohio Children’s Hospital Bundle for Readmissions

The Ohio Project Bundle• The Ohio Project is a collaborative of hospitals dedicated to improving patient safety based on JCAHO recommendations.

• The Readmission Bundle consists of:– Identify high-risk patients – those that are most likely to

be readmitted.– Review every readmission and determine preventability

– what can we do different to keep these kids home.– Provide feedback to clinicians on readmit rate – Standardize the discharge process

Small Test of Change• Pre and Post Surveys assessing knowledge

• 23 pre -surveys with 14 returned (61%)

• Educational program consisting of:– hand-outs – Huddles– information posted in clinic and our division office.

• I sent out 14 post-surveys and got 8 back (57%)

RESULTS

Pre Survey Post Survey0

0.1

0.2

0.3

0.4

0.5

0.6

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0.8

0.9

1

Question 1Question 2Question 3

Repeat Visits to Clinic• Retrospective Chart Review for Clinic Visits in Jan 2013

• Clinic visits scheduled: 520• Actual patients seen: 364• No shows: 46 (9%)• Cancel/Reschedules: 137 (26%)• Number of repeat visits: 26 (5%)

• Note: Our no show rate will increase as now we are marking all cancels/reschedules that happen day of clinic as no shows.

 

Hospital Readmissions

Nov 2012 – Jan 2013

Total admissions for GI48

Total readmissions for GI 17 (35 %) 

Challenges and Rewards

• The pre-survey was well received and received enough responses to go forward with my project.

• Getting on the agenda at our Monday meeting was a challenge and this put me behind about a week.

• Getting post-surveys returned was very difficult and affected my results

• After all was said and done I said a big thank you to my team for their participation and support.

Next Steps• Recommendations:

– increase the use of the outpatient RN with the inpatient population and

– work toward standardized discharge teaching for those kids going home with specialized feeds and injections.

• Further Evidenced-Based work looking at whether standardized discharge teaching decreases readmissions.

REFERENCESBerry, MD., J & et al. (2013). Pediatric Readmission Prevalence and Variability Across

Hospitals. JAMA, 309(4), 372-380.

Bisset, A.F. (1998). The case for clinical audit of emergency readmissions after appendicetomy. The Royal College of Surgeons of Edinburgh, 43; 257-261.

Feignenbaum, MD, P., & et al, (2012). Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Medical Care, 50(7),

599-605.

Gay, J.C., & et al. (2011). Epidemiology of 15-Day Readmissions to a Children’s Hospital. Pediatrics, 127(6); 1505-1512. Retrieved from Pediatrics.aappublications.org

Hain, P.D., & et al. (2013). Preventability of Early Readmissions at a Children’s Hospital. Pediatrics, 131(1); 171-182. Retrieved from Pediatrics.aappublications.org

Halfon, MD., P. & et al. (2006). Validation of the Potentially Avoidable Hospital Readmission Rate as a Routine Indicator of the Quality of Hospital Care. Medical

Care 44(11); 972-981

REFERENCESMugford, M., Banfield, P., & O’Hanlon, M. (1991). Effects of feedback of information

on clinical practice: a review. BMJ 303; 398-402.

Njeim, MD, M & et al. (2012). System-Based Approach to Educating Internal Medicine Residents on Preventable Hospital Readmissions. Journal of Graduate

Medical Education, 505-509. Retrieved from dx.doi.org

Perez, F.D., & et al. (2013). Characteristics and Direct Costs of Academic Pediatric Subspecialty Outpatient No-Show Events. Journal for Healthcare Quality,

pp.1- 11.

Stevens, et al. (2007). A qualitative examination of changing practice in Canadian neonatal intensive care units. Journal of Evaluation in Clinical Practice, 13;

287- 294.

VanSuch, M., & et al, (2006). Effect of discharge instructions on readmissions of hospitalised patients with heart failure: do all of the joint commission on accreditation of healthcare organizations heart failure core measures

reflect better care?. Qual Saf Health Care, 15(414), Retrieved from www.qshc.com

Thank you!

• My cohorts: Maggie Church, RN, BSN

Karen Hartley, RN, BSN• My mentors: Annette Nasr, RN, PhD.

Linda Ikuta, RN, MSN

Kari Ksar, PNP, MSN

Amy Fisher, RN, MSN