October 1, 2015

OR team uses evidence-based practices to reduce readmissions

By: OR Manager

Concerted efforts to reduce readmissions have paid off at Inova Fairfax Hospital in Falls Church, Virginia. Among its bragging rights since launching an initiative last year: decreased length of stay for colorectal surgery patients and a downward trend in readmissions.

To learn how they did it, OR Manager spoke with Paula Graling, DNP, RN, CNOR, FAAN, clinical nurse specialist in the department of surgery at Inova Fairfax and education and clinical director for the Advanced Surgical Technology and Education Center, a simulation center.

Inova Fairfax, a member of a five-hospital system with an annual volume of 30,000 procedures, started an initiative in February 2014 to reduce readmissions.

Ultimately, the length of stay for colorectal patients decreased by 1 1/2 days for those who had open procedures, and by 1/2 day for those who had minimally invasive procedures.

The readmission rate for colorectal patients is trending downward, as indicated by the observed-to-expected (O/E) outcome ratio, from 2 before the initiative to 1.3—well on its way to the target of less than 1.


Incentive to improve

The formal effort to reduce readmissions originated with the chair of the surgery department, who, as Graling says, “was getting pulled up to administration and asked about readmission rates of surgical patients. He wanted to have a grassroots, proactive discussion of the issue.” That led to the formation of a broad-based team to address readmissions after colorectal surgery.

Inova Fairfax has a hybrid model of both employed and community physicians. The chair of surgery is an employee, which enables him to set the direction for the department on a consistent basis without competing priorities and enhances his ability to influence participation of residents in projects.

The vice chairman of quality and a nurse who focuses on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) chair the team.

In addition to Graling, team members include the OR director, service line leaders, case manager, ostomy nurse, infection prevention nurse, staff nurses from the units where postoperative patients go, and the statistician for the department of surgery.

“We brought everyone together,” says Graling. “Everybody had to be aware that somewhere along the way, they bring something that affects whether a patient is readmitted.”

The group formed two subteams: one to tackle readmission after ileostomy and the other to tackle infections after colorectal surgery.

Initially, Graling says, physicians resisted efforts, saying, “It’s not my patients who have problems.” However, as the teams focused on the aggregate data, the physicians became more supportive.


Results and actions

The ileostomy team found that the primary cause for readmission was dehydration, but they also identified other opportunities for improvement among ostomy patients in general. That led to the following actions, several of them specific to the OR:

• Providing and reinforcing education preoperatively.

• Creating an algorithm for preoperative care in the OR, including skin prep and insertion of urinary catheters.

“We looked at the evidence to develop the algorithm,” Graling says. Staff practice insertion of urinary catheters in the simulation lab, and clinical service leaders observe insertions routinely to ensure competence.

• Reinstating a closing tray for use in colorectal surgery.

“Evidence shows that this helps reduce infections,” Graling says. Staff and surgeons resisted at first, but the service leader of colorectal surgery set up a proposed closing tray in the simulation lab to obtain input.

“The decision as to what would be in the tray was made by them [OR staff and surgeons],” Graling says. “They decided on the nuts and bolts.”

• Stocking appropriate ostomy supplies in the OR. Adding an ostomy nurse to the team improved understanding of patient needs postoperatively and made it possible for OR and ostomy nurses to collaborate more closely.

• Ensuring a smoother transition for residents coming into or leaving the colorectal surgical service. The chief residents developed a packet of resources for new residents rotating into the service.

• Involving nutritionists earlier in the patient’s stay.

“Nutritionists are like the canary in the coal mine for problems,” Graling says.

• Developing flip charts for patients that list specific goals for their care. For example, on the first postoperative day, patients are told they will walk 50 feet and empty the ostomy bag.

Charts can be customized to the patient. “A lot of people use white boards for this, but we had too much information,” Graling says.

• Standardizing for multiple “touches” with the patient after discharge. These steps include a call from the ostomy nurse to check on the patient and, depending on the patient’s condition, a visit to the ostomy clinic or a visit by a home health nurse to the patient’s home.

• Extending the hours for the ostomy clinic.

• Providing patients with more community resources.

“Our relationship with the visiting nurse association has really strengthened,” Graling says.

The full team now meets monthly to review a score card for infection prevention.

The infection prevention nurse shares data on infections, the statistician provides data such as readmission rates and quality measures, and the NSQIP nurse provides additional information.

When taking on readmission prevention efforts, Graling says, “You can’t beat yourself up if you haven’t reached benchmarks.” She recommends talking with colleagues regionally and nationally.

“Don’t be afraid to try something as long as it’s evidenced-based,” she advises.

To sustain momentum for the long term, she says, “Continue to be curious, look at the evidence, and innovate. Drive yourself to be the best.” ✥


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