Pediatric Hospitals Develop Best Practices to Avoid Readmissions
More than 135 children’s hospitals nationwide have shared best practices and strategies for improving safety and health outcomes for their young patients. The Children’s Hospitals’ Solutions for Patient Safety (SPS) is a collaboration that has helped some hospitals reduce their readmissions rates and improve safety and care quality.
This group of children’s hospitals has taken the bundles of care approach, applying a bundle of their best practices to see how these impact outcomes, says Cyndi Fisher, RN, MSN, CPNP, ACM, director of case management and care connection at the Children’s Hospital of The King’s Daughters (CHKD) in Norfolk, VA.
“We did that at The King’s Daughters for readmissions,” Fisher says.
Dayton Children’s Hospital was one of the original eight Ohio hospitals that banded together to form a collaboration on safety.
“Originally, we were called the Ohio Children’s Hospital Solutions for Patient Safety,” says Hila Collins, MS, RN, CPNP-AC, CIC, director of clinical safety at Dayton Children’s Hospital.
“Now that we’re national — and international with Canada hospitals — we’re just Solutions for Patient Safety,” she says. “When we sat at the original table in Columbus, OH, we wanted to make it very clear that our mission was to eliminate harm.”
The Ohio children’s hospitals are competitors, but not when it comes to patient safety: “We made a very intentional decision that it was much more important that we could teach and learn from one another about pediatric patient harm reduction, and there was not going to be any competition,” Collins explains.
The SPS National Children’s Network has a goal of harm reduction by Dec. 31, 2021. The goals include improving pediatric care and cutting Medicaid costs. (For more information, visit: https://bit.ly/2SbnKQP.)
“If there is one hospital among the 135 that has something working very well, then they’ll talk about it so we can implement [best practices] at our place,” Collins says. “We have an overarching philosophy of adopt, adapt, or abandon.”
At CHKD, best practice strategies are working: Internal data show reductions in both seven-day readmission rates and 30-day readmission rates, Fisher says.
For example, CHKD’s internal data show that in 2015, the seven-day readmission rate was 4.23 per 100 discharges. This had declined to 3.19 per 100 discharges in 2017 — a reduction of nearly 25%. Also, the 30-day readmission rate dropped by about 16% in that same period of time: it was just over nine per 100 discharges in 2015, and it fell to 7.57 per 100 discharges in 2017.
Hospitals involved in the Solutions for Patient Safety learn small safety best practices, such as using visual cues that remind staff that a patient is at risk of falling. They might share more complicated strategies like using an algorithm in the electronic medical record to inform decision-making about patients’ vital signs, Collins says.
“We focus on hospital-acquired conditions and one top one is catheter-associated urinary tract infections [CAUTIs],” Collins says.
After setting a goal of reducing CAUTIs, the hospital developed best practices from research findings and learned strategies from other hospitals. The result was a reduction of more than 30% in catheter days and no CAUTIs over a two-year period, she says.
CHKD achieved the positive readmission outcomes through several best practice steps, which include having case managers help patients eliminate obstacles to maintaining their health. These best practice steps include the following:
• Identify readmitted patients.
“If patients return to the hospital and we have a readmission, that’s where we identify opportunities for improvement,” Fisher says. “If the patient returns within seven days, we look at this to see if this was a planned or unplanned hospital stay, and then we do a chart review.”
For example, the chart review might reveal that the patient never scheduled a follow-up appointment.
On some of the readmissions, there will be a family survey.
“We want to see what their experience was and if the readmission could have been prevented,” Fisher says. “Additionally, we notified both the physician discharging the patient as well as the physician readmitting the patient to see if there was anything from their perspective that could have made this encounter avoidable.”
For example, if the patient did not take antibiotics after hospitalization for an infection, then the patient’s illness could continue or a secondary infection might occur. “We’re dependent on the parents to follow through on the things they need to do,” she says.
In another example, a patient might be discharged with an order for oxygen at home. If the durable medical equipment (DME) company doesn’t provide the oxygen equipment before the child’s bed time, the family might have no choice but to bring the child back to the hospital to ensure the child can sleep safely through the night, she adds.
“We have to depend on the home care company and DME company to do what they need to do for the family,” Fisher says.
• Design best practice processes.
“Everybody approaches best practices their own way at their hospital,” Fisher notes. “Ultimately, I think these should be based on the research and work that’s been done at readmissions.”
For example, CHKD staff identified helpful practices, such as making sure that families at discharge scheduled follow-up appointments and had a contact number for those appointments.
Also, patients identified as high-risk for readmissions because of their dependence on post-acute services or medications receive post-discharge follow-up calls, Fisher says.
For instance, the patient might be in the hospital for treatment of an infection. The patient is weaned off the IV antibiotic but now is prescribed a regimen of oral antibiotics to prevent recurrence. This patient’s family could benefit from a follow-up call to confirm that the family was able to pick up the medication within two days. If the family could not afford the medication, then a case manager could help them obtain a voucher. Or if there was a delay because of insurance authorization, the case manager could call the patient’s pharmacy benefit manager to get authorization, taking care of whatever barriers arise, she explains.
• Follow-up with case management.
“We provide the care, reinforce what it is the family needs, and we make sure they’re in good shape,” Fisher says. “Then my administration team does a post-discharge follow-up phone call to make sure they have everything they need.”
The initial phone calls follow a script, such as this one: “Hi, this is nurse from case management. I am calling to check on how things are going since you were discharged from the hospital…”
The caller asks questions, such as these from the CHKD case management discharge follow-up survey:
- Did you feel prepared to care for your child at home after discharge?
- Did the home services agency/agencies contact you as planned?
- When are you scheduled to follow up with your child’s physician?
- Were you able to obtain the prescription or formula that was ordered?
“We document responses,” Fisher says.
If the family has a concern or if there is a problem, the caller obtains the family’s best contact phone number and refers the patient to the case manager for further follow-up, she adds.
A group of children’s hospitals has taken the bundles of care approach, applying a bundle of their best practices to see how these impact outcomes.
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