September 22, 2015

Infection prevention tops list of readmission ‘action items’

By: OR Manager

Although most patients spend a brief time in the OR, what happens there significantly impacts a hospital’s 30-day readmission rate. According to a 2015 study in JAMA, complications related to the surgical procedure are the most common cause of readmission after surgery.

The researchers analyzed data from the American College of Surgeons National Surgical Quality Improvement Program. The 30-day readmission rate for the six representative operations included in the study (bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass) was 5.7%, with surgical site infection (SSI) the most common reason for readmission.

Another 2015 study, published in JAMA Surgery, reported a 30-day readmission rate of 13.2% for surgical patients, with considerable variation across surgical subspecialties. Patient-related factors, including postoperative complications, higher comorbidity, and extended length of stay, accounted for most of the variation.

According to an August 2015 report from Kaiser Health News, most US hospitals (2,592 in all) will be penalized a total of $420 million in October for missing readmission targets.

The Hospital Readmissions Reduction Program includes patients originally hospitalized for heart attack, heart failure, pneumonia, chronic lung problems, or elective hip or knee replacement surgery.

Data like these point to the need for OR staff to participate in reducing readmissions. “The surgical episode is one element in the continuum of care, so the tendency is to believe that those in the OR can’t do much to reduce readmissions,” says Amy Bethel, MPA, RN, NE-BC, from UnityPoint Health in Des Moines, Iowa. “But they can. Probably the most important thing they can do is stick with the SCIP [Surgical Care Improvement Project] guidelines.”

In fact, infection prevention measures topped the list of actions OR leaders have taken to reduce readmissions, according to an open-ended question from the 2015 OR Manager Salary/Career Survey (see sidebar, p 14).

As more hospitals move to bundled payments for surgical procedures, additional emphasis on preventing readmissions is likely.

“Bundled payments have significant implications for readmissions,” says Cindy Arcieri, MS, APRN, OCN, vice president of patient care services and chief nursing officer at St Joseph Hospital in Nashua, New Hampshire. With bundling, hospitals are responsible for costs that exceed the bundled rate, such as readmission within 30 days for a procedure-related complication.

Another motivator for reducing readmissions is the need to improve patients’ satisfaction scores related to discharge on the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which can affect reimbursement.

OR leaders and staff can play an important role in unit- and hospital-based initiatives to reduce readmissions.


Amy Bethel, MPA, RN, NE-BC

Amy Bethel, MPA, RN, NE-BC

Building a team

As is the case with most initiatives, a team approach to reducing readmissions boosts the chance of success. “We work to engage all leaders about global issues such as value-based purchasing and preventing readmissions,” Arcieri says. “They may be just one piece of the pie, but everyone has a critical role in that pie.” Engagement takes the form of education and discussion.

Bethel adds that staff need to be educated because often times they believe reducing readmissions doesn’t apply to them.



Covering the basics

Many of the basic measures OR leaders and staff focus on can influence readmissions. “You have to be meticulous about that [the OR] episode of care,” Bethel says. That includes ensuring SCIP measures are met. Any outliers should be immediately reviewed and addressed.

At St Joseph Hospital, Arcieri says, OR leaders track those who don’t follow SCIP guidelines. “Anyone who doesn’t follow them first gets a notification and reeducation,” she says. “If that doesn’t work, there is a peer-to-peer conversation to improve performance.”

Even the basic surgical safety checklist is important in preventing readmissions: A 2014 study in the Scandinavian Journal of Surgery found that use of the checklist was associated with reduced wound complications and readmissions.

Follow-up after surgery is important, too. Given that infections frequently result in readmissions, it’s crucial to teach patients about early signs and symptoms of infection and what action to take should they occur.

Bethel says at her facility, outpatients receive calls the day after surgery to check for postoperative complications, verify that pain medicine prescriptions have been filled, assess pain, and ensure the patient has a follow-up appointment scheduled.

Those looking to better the quality of those calls might want to review a tool on this topic from the Re-Engineered Discharge (RED) Toolkit from the Agency for Healthcare Research and Quality. The tool notes that the call consists of five components:

• assessment of health status

• medicine check

• clarification of clinician appointments and lab tests

• coordination of postdischarge home services

• review of what to do if a health or medical problem arises.

The tool includes a documentation form for the calls.

Cindy Arcieri, MS, APRN, OCN

Cindy Arcieri, MS, APRN, OCN

Broadening the focus

Preventing surgical-related hospital readmissions is more likely to succeed if staff pay attention to risk factors for developing infections or other problems likely to land patients in the hospital after surgery.

“We’ve been making a concerted effort to identify patients at risk early on so they can get the resources they need,” Arcieri says. Factors that raise a red flag include advanced age, comorbidities, multiple medications, and lack of support systems at home. Hospitalists at St Joseph Hospital follow patients with comorbidities.

Bethel says UnityPoint Health staff also focus on patient comorbidities such as diabetes and heart failure.

“If our quality department sees anything problematic, they communicate with the appropriate leaders and staff to develop a correction plan,” she notes.

Anesthesia providers can help reduce readmissions by considering patients’ comorbidities such as heart failure when choosing and delivering anesthesia and implementing effective glycemic control in patients with diabetes.

Arcieri says the case management team uses the Geisinger Health Systems’ ProvenHealth Transitions tool before patients are discharged.

“If they score a high number, we’ll be sure they have the resources they need, including early follow-up with providers,” she says.


Getting it right

Arcieri says preventing readmissions is good financial stewardship. “We can use money saved for other initiatives and for quality efforts.”

But she adds that the primary reason for preventing readmissions is, “We want to get it right the first time. We know you’re going to have a small percentage of patients where problems occur, but we want to keep that as low as possible. It’s a matter of quality care.”

Specific strategies that have reduced readmissions at one facility are described on p 18. ✥




Agency for Healthcare Research and Quality. Re-engineered discharge (RED) toolkit. 2015.

American Hospital Association. Private-sector hospital discharge tools. 2015.

Gani F, Lucas D J, Kim Y, et al. Understanding variation in 30-day readmission in the era of accountable care: Effect of the patient, surgeon, and surgical subspecialities. JAMA Surg. Published online August 5, 2015.

Lepänluoma M, Takala R, Kotkansalo A, et al. Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg. 2014;103(1):66-72.

Merkow R P, Ju M H, Chung J W, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015;313(5):493-495.

Rau J. Half of nation’s hospitals fail again to escape Medicare’s readmission penalties. Kaiser Health News. August 3, 2015.

Meeting challenge of readmissions

As part of the 25th annual OR Manager Salary/Career Survey, we asked, “What process changes have you implemented in the past 12 months to reduce hospital readmissions?” Nearly 100 respondents commented, with most identifying infection prevention as the focus of their efforts. Many of their sample comments, organized by issues identified, suggest ways OR leaders might reduce readmissions in their own organizations.

Infection prevention

• Vigilance in monitoring SSIs (surgical site infections) to ensure they remain less than 3%.

• New process for cleaning of ORs with control markers being placed in ORs to ensure that appropriate terminal cleaning is being done on routine basis.

• 100% compliance with Surgical Care Improvement Project criteria.

• Better education for staff—prepping of patients.

• Lowered SSIs.

• Implementing bowel closure protocol.

• Colorectal SSI bundle.

• Changes in manual cleaning of our scopes.

• Cleaning of instruments.

• Professionally laundered scrubs in the OR.

• Double gloving, glove changing, sterile technique reviewed.

• Collaborative huddles and Lean techniques between case management, physicians, and Visiting Nurse Association.

• Focus on surgical site infection prevention.

• Active management and daily reporting of all readmissions and reasons for readmission, shared daily at management huddles.

• Immediate use sterilization of instruments is monitored to provide needed instruments to keep this less than 3%.

• Systemwide hand hygiene strategy.

• Focus on total joint replacement/spine patients receiving appropriate preoperative preparation—CHG (chlorhexidine gluconate).

• Foley catheter changes and education.

• Central line process changes.

• Endoscopy sterilization process changes.

• Infection control surveillance reporting with our surgeons.

• Notification to surgeons about SSI. Letters are sent to physicians, and this is brought up at medical staff meetings.

• Removal of immediate use steam sterilization autoclaves in the OR.

• Surgical hand scrub and surgical skin prep task forces.

• Revamped sterile processing department to mirror recommendations from the Joint Commission and AORN.

• Surgical attire and dress code modifications.

• Removal of all corrugated boxes from department as well as books, magazines, and documents on walls (that are not laminated).

• Targeted education for SSIs.


Patient-related initiatives

• Preoperative CHG showers when appropriate.

• Better education with patients regarding hygiene before and after surgery.

• Better postoperative instructions with family involvement and follow-up within 24 hours and 1 week later.

• Call to patients within 24 hours of discharge/discharge phone calls.

• Community care coaches visiting patients in their homes after discharge.

• Community liaison for the emergency department.

• Discharge planning huddle on day of admission used to create expected care path and set expectations with patient.

• Education and a number to call with questions—discharge planner stays in communication with patient.

• Embedded care coordinators.

• Follow-up appointment within 2 weeks.

• Follow-up care with a home specialist employed by the hospital.

• For our total joint replacement patients, a med/surg nurse educates patients about the days in the hospital post procedure.

• Health mentors.

• Increased occurrence of preoperative clearances, moved clearances further out from the date of surgery, more full-time equivalents in preoperative clearance, more detailed clearance.

• Handing out SSI education during preadmission testing appointment.

• Obstructive sleep apnea screening.

• Revamping discharge instructions.

• Several Amish in my community seek care at our hospital. The use of salves and herbal applications at home has led to SSIs requiring our attention. We have instituted preoperative videos that detail proper postoperative care, and we have addressed the subject during the discharge process.



• Readmission team.

• Anesthesia chart review.

• Enhanced Recovery After Surgery protocol, which begins in the preadmission standard work.

• We are implementing the perioperative surgical home.

• Medical home, care coordination, surgical pathways.

• Increasing awareness of community/population health throughout the organization.

• Population health specialists.

• Utilization review, computerized charting, hospitalists, quality management division.

• Project BOOST (Better Outcomes by Optimizing Safe Transitions).

• Hospital-wide transformation department that reports directly to the CFO. Responsible for managing readmissions, utilization of services, continuity of care. We are part of the Delivery Systems Transformation Initiative waiver program through the Centers for Medicare & Medicaid Services, which provides funding for hospitals to initiate transformative care in line with the transition toward accountable care organizations.

• Education to providers, staff, and patients. I cannot emphasize enough the importance of education!

Meeting challenge of readmissions

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