Collaboration eliminates sepsis readmissions

Hospital, SNF targeted HF patients

When St. Anthony's Hospital and Pinellas Point Nursing and Rehabilitation, both located in St. Petersburg, FL, collaborated on a project to reduce heart failure readmissions, the team determined that many readmissions were for sepsis. They embarked on a project that eliminated sepsis as a reason for readmission in just six months.

The initiative grew out of a case management-led initiative to analyze readmission rates and develop strategies to reduce the readmissions in advance of the Centers for Medicare and Medicaid Services' plans to penalize hospitals with excessive high readmission rates beginning October 1 of this year. The initial analysis showed that while 11-12% of patients discharged to home were being readmitted within 30 days, the figure rose to 22% among patients being discharged to extended care facilities.

"We saw this as an opportunity to develop a partnership with post-acute providers to better control the situations that lead to readmissions. We decided to zero in on the heart failure population, and translate the lessons to other patient populations. Our first project was to join forces with Pinellas Point Nursing and Rehabilitation and come up with ways we could work together to prevent readmissions," says Patricia Sizemore, RN, BSN, MA, vice president of patient nursing for the 395-bed hospital.

Case management took the lead in the readmission reduction project, developing risk assessment tools and conducting an analysis to determine what patients were being readmitted, and when and what could be done to reduce the readmissions, says Julie Losee, RN, BSN, manager of case management and clinical services.

St. Anthony's team drilled down on data from Pinellas Point readmissions and determined that 56% of heart failure patients being readmitted within 30 days had a diagnosis of sepsis rather than a cardiac diagnosis. The hospital assembled a multidisciplinary committee from St. Anthony's and Pinellas Point, including representatives from social services and case management at both facilities, the nursing and medical directors at the skilled nursing facility, and the skilled nursing liaison.

"We met monthly for several months and looked at what we were doing in the hospital before the patients left and what was happening in the skilled facility. We analyzed the situation and came up with ways we could decrease readmission rates," Losee says.

The team asked the nursing facility representatives what information they needed when patients were transferred, and surveyed physicians who cover the skilled nursing facility to determine what laboratory tests results they needed from patients being admitted, and what order they should be in. Now, the hospital sends the standardized information to the nursing facility during the transfer process, allowing the nursing facility physicians to quickly review it at admission.

The team developed a sepsis screening tool that the nursing facility staff used for every shift for the first 15 days of the skilled nursing admission, to track temperature, heart rate, respiration rate, and any changes in the patient's acute status. The protocol calls for a urine culture and a complete blood count to be completed on the third day of admission, and for the staff to contact the nursing facility medical director and the patient's primary care physician if any part of the screening criteria is positive.

Sizemore points out that physicians who cover skilled nursing facilities traditionally visit patients once a month and don't typically come to the facility for emergencies. When the facility calls the doctor because a patient has a fever, the typical response is to tell the nurse to send the patient to the hospital emergency department for treatment. "We know that hospital admissions are disorientating for elderly patients as well as contributing to increased healthcare costs. We are working to diagnosis problems earlier and take steps to treat them in the skilled facility," she says.

The hospital helped the facility develop protocols so that the physicians could implement interventions instead of sending patients back to the emergency department. "When the symptoms were identified earlier, there was an increased cost for antibiotics, but a decrease in the readmission rate," she says.

The hospital is now partnering with another skilled nursing facility in the community on a sepsis prevention protocol. "In this project, we are looking at patients with multiple diagnoses to determine if they are being readmitted because of sepsis," Sizemore says.

Losee says that the case managers at St. Anthony's work with the skilled nursing facility's liaison to ensure a smooth transition. "We make sure that the patient education is complete and that the facility gets all the information it needs to meet the needs of the patients being transferred," she says.