Surg patients pre-screened for discharge issues pre-op

Clinics, hospital staff work to prevent readmissions

By the time the majority of patients having elective surgery are admitted to Geisinger Health System, the care managers who will coordinate their care after surgery already have the information they need to create a discharge plan.

The hospital system began its program to reduce readmission rates for the majority of patients having elective general surgery in May 2008. Patients eligible for the program are undergoing gastric bypass surgery, oncological surgery, bowel resections, and other general surgeries.

When these patients visit the clinic for their preoperative appointment, the clinical nurse specialists complete a risk assessment screening that includes questions about age, living situation, mobility issues, the number of medications, and any hospital or emergency department visits in the past 12 months.

"What makes this process different is that the hospital is coordinating with the clinic prior to admission. We take the information gathered in the clinic and follow up in the hospital and as the patient transitions to the community," says Heide Feele, MSW, ACS, social work care coordinator who partners with an RN care manager to coordinate care for patients on the surgical floor.

The hospital care coordinators receive information on patients who are at high risk for readmission before patients have surgery.

"When the patient is on our floor, we use that information and the information from the preadmission screening calls when we follow up with the patients after admission. If there is likely to be a discharge issue, we can take care of it before admission," Feele says.

For instance, rural home care agencies typically have a two to three day waiting list. When patients are coming from those areas, the care managers call the agencies on the day of surgery and give them a heads up so a nurse will be available to see them at home when they are discharged, Feele says.

The care managers see patients on the surgical unit on the day following surgery. "Some of the patients go to the ICU or a telemetry unit. They're not fully included in the project unless they come on our floor," she says.

Using flowsheets

The goal is to expand the pilot program to the special care and telemetry floors and to include all patients who receive scheduled surgery.

The care managers follow patients until discharge using flowsheets that include clinical milestones for each day of admission. The nursing staff use similar flowsheets.

"We focus a lot on the support system at home and their chronic medical conditions. We get physical therapy and occupational therapy consults ordered as early as possible and spend a lot of time educating them on wound care, drain care, and other needs they will have after discharge," she says.

The teaching on the floor is reinforced by the home care agency, she says.

The care managers help the patients and families have realistic expectations of the care they will receive after discharge.

"Some patients think that when they go home, a nurse will come out once or twice a day. We educate them on the care they will have to provide on their own," she says.

When patients unexpectedly need to spend time in a skilled nursing facility, the team can give them a virtual tour of facilities on a laptop computer.