Transitional care services: a quality and safety process improvement program in neurosurgery

Abstract

OBJECTIVE Readmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. However, few readmission reduction programs have targeted surgical patient populations. The objective of this study was to establish a transitional care program (TCP) with the goal of decreasing length of stay (LOS), improving discharge efficiency, and reducing readmissions of neurosurgical patients by optimizing patient education and postdischarge surveillance. METHODS Patients undergoing elective cranial or spinal neurosurgery performed by one of 5 participating surgeons at a quaternary care hospital were enrolled into a multifaceted intervention. A preadmission overview and establishment of an anticipated discharge date were both intended to set patient expectations for a shorter hospitalization. At discharge, in-hospital prescription filling was provided to facilitate medication compliance. Extended discharge appointments with a neurosurgery TCP-trained nurse emphasized postoperative activity, medications, incisional care, nutrition, signs that merit return to medical attention, and follow-up appointments. Finally, patients received a surveillance phone call 48 hours after discharge. Eligible patients omitted due to staff limitations were selected as controls. Patients were matched by sex, age, and operation type-key confounding variables-with control patients, who were eligible patients treated at the same time period but not enrolled in the TCP due to staff limitation. Multivariable logistic regression evaluated the association of TCP enrollment with discharge time and readmission, and linear regression with LOS. Covariates included matching criteria and Charlson Comorbidity Index scores. RESULTS Between 2013 and 2015, 416 patients were enrolled in the program and matched to a control. The median patient age was 55 years (interquartile range 44.5-65 years); 58.4% were male. The majority of enrolled patients underwent spine surgery (59.4%, compared with 40.6% undergoing cranial surgery). Hospitalizations averaged 62.1 hours for TCP patients versus 79.6 hours for controls (a 16.40% reduction, 95% CI 9.30%-23.49%; p < 0.001). The intervention was associated with a higher proportion of morning discharges, which was intended to free beds for afternoon admissions and improve patient flow (OR 3.13, 95% CI 2.27-4.30; p < 0.001), and decreased 30-day readmissions (2.5% vs 5.8%; OR 2.43, 95% CI 1.14-5.27; p = 0.02). CONCLUSIONS This neurosurgical TCP was associated with a significantly shorter LOS, earlier discharge, and reduced 30-day readmission after elective neurosurgery. These results underscore the importance of patient education and surveillance after hospital discharge.

Examining Length of Hospital Stay after Microsurgical Breast Reconstruction: Evaluation in a Case-Control Study

“…In the current health-care climate, multiple metrics have been evaluated in an effort to improve patient outcomes in a most cost-efficient manner. 13 , 14 Postsurgical length of inpatient hospital stay has become a commonly utilized metric in this regard. 13 , 14 , 16 – 18 The rise in implementation of enhanced recovery pathways after autologous breast reconstruction has mirrored the effort to reduce postoperative LOS and associated costs.…”

“… 13 , 14 Postsurgical length of inpatient hospital stay has become a commonly utilized metric in this regard. 13 , 14 , 16 – 18 The rise in implementation of enhanced recovery pathways after autologous breast reconstruction has mirrored the effort to reduce postoperative LOS and associated costs. 13 , 14 , 16 – 19 , 21 For instance, Afonso et al demonstrated significantly reduced length of hospital stay after autologous breast reconstruction with implementation of an enhanced recovery pathway comprised of reducing opioid-centered pain management, regional abdominal blocks, and goal-directed fluid therapy, among other changes.…”

“…Meanwhile, length of postoperative hospitalization is becoming an increasingly utilized surgical outcome metric. 13 , 14 With regard to autologous breast reconstruction, increased length of hospital stay has unsurprisingly been linked to increasing health-care cost. 15 Multiple studies have also evaluated the influence of specific interventions or enhanced recovery pathways on outcomes after autologous breast reconstruction, including length of hospital stay.…”

A quality improvement curriculum for the neurology clerkship: A practice-based approach to discharge education

“…Preventing readmission rests on improved discharge education and optimized outpatient follow-up. Specifically, discharge education is one of the interventions that has been shown to help reduce overall unplanned hospital readmissions at 30 and 90 days [1] for a variety of medical conditions, which include stroke [[2], [3], [4], [5], [6]], congestive heart failure, and diabetes [7,8]. There is inherent value in training future physicians how to provide patient-centered discharge education.…”

Reducing ED Re-admissions in Post-Op Neuro Patients utilizing a NP Telephone Follow-up Protocol

“…The time of discharge is chaotic and the patients experience an overwhelming amount of new information at the time. Robertson et al (2018) found that SSI (surgical site infection) rates may be reduced though discharge planning strategies and targeted patient education. If the patient was inadequately engaged or lacked comprehension, it affected the compliance and recognition of complications, placing them at risk for readmission.…”