The government and insurance companies have imposed increasing penalties on healthcare facilities in recent years for readmissions. And with good reason: High readmission rates greatly increase costs and sometimes signal poor patient safety practices.
In 2015, roughly 2 million patients were readmitted, costing Medicare $27 billion, according to the Centers for Medicare & Medicaid Services, and $17 billion was spent on readmissions that were potentially avoidable.
Knowing which patients are at high risk for readmissions and optimizing their health before surgery are key to reducing readmissions. Numerous studies support the merits of these practices, and tools such as the American College of Surgeons National Surgical Quality Improvement Program’s surgical risk calculator have been developed to help clinicians better assess risk.
Perioperative leaders at UPMC Pinnacle in Harrisburg, Pennsylvania, have taken a closer look at their surgical patient population and identified the ingredients for a winning patient optimization “recipe.”
“If you look at the research, there are a number of reasons why patients are being readmitted,” says Tina Frank, MHS, BSN, RN, senior systems director for peri-optimization, general surgery and bariatric service lines at UPMC Pinnacle. These include complications, age, procedure, and comorbid conditions (sidebar below).
In addition to increased costs for readmissions, there are the increased costs from same-day surgery cancellations. These are costly not only because of the wasted supplies, downtime in the OR, and the effect on the preop staff trying to call in the next patient, but also because of the impact on patient satisfaction, says Frank.
“One cancellation affects not only that patient, but also all the other patients for the rest of that day,” Frank notes.
Surgical cancellations can be related to two different situations:
• structural cancellations—there isn’t an OR or staff available, or there are emergency cases
• patient-related issues, such as a patient with a blood sugar of 400 or a blood pressure of 200 over 110 on the day of surgery.
“We looked at all of these statistics and saw an opportunity with these high-risk patients,” says Frank. “It was a matter of trying to figure out what we needed to do to optimize these patients in order to reduce the readmissions, complications, and cancellations.”
Frank, along with a group of surgeons and administrators, came up with a plan for patient presurgical optimization. They defined this as the “process in which patients are adequately prepared for surgery,” and it includes:
• care coordination between surgeon, primary care provider, anesthesia team, and hospital
• detailed patient assessment and treatment of current conditions and modifiable risk factors
• patient education
• counseling and support
“Our patients tell us, I have never gotten my money’s worth like I have here because you actually sat down and talked to me. I finally understand my diabetes. I finally understand what I need to do to lose weight. I finally have the resources I need to stop smoking,” says Frank. “We have created our recipe for success.”
Many of these patients are suddenly motivated on a new level to make changes they should have been making all along—changes that their primary care physicians have been trying to get them to make, says Teresa Diez, CRNP, MSN, Surgery Optimization Clinic, UPMC Pinnacle.
Diez notes that this process is not the same as that of a preadmission testing clinic. They are taking the high-risk patients with the most comorbidities and higher risk issues—about 13% to 20% of surgical admissions—and they are optimizing their modifiable risk factors.
Gather ingredients. Using the recipe analogy, Diez says to create a recipe for success, the right ingredients have to be gathered, which correlates to getting the administration, surgeons, and primary care providers on board.
“We needed to get the cooperation of the primary care providers because we didn’t want to usurp their practice and take over what they’ve done for many years with their patients. We had to let them know we wanted to assist them and work together collaboratively and intensively to manage their patients before surgery for better outcomes,” says Diez.
In addition, there needs to be a space for the clinic and the clinic providers, such as nurse practitioners; clinical care coordinators for follow-up; and support staff to help patients into a room and input information into a computer.
Preheat the oven. This means “preheating” the surgeons or discussing what the bottom line is for them, reviewing the purpose of the clinic, and identifying the target population.
The clinic got started as a result of the bundled payment system in 2015. “Everyone was getting dinged on reimbursement if they had a readmission or prolonged length of stay,” says Diez. This made the surgeons more engaged than before.
The team wanted to make sure the surgeons understood how the patient optimization clinic could make a difference for their patients. “We told them the purpose of the clinic was to decrease or do away with readmissions, same-day cancellations, longer lengths of stay, and complications,” says Diez.
The next step was to identify their patient population because they didn’t want everyone coming to the clinic, only those who needed intensive management before surgery.
The clinic referral criteria they came up with included:
• BMI >40 or >35 with two comorbidities—overweight patients have more surgical site infections, blood clots, pulmonary function issues, and other metabolic issues.
• Frailty—some older patients aren’t strong enough to have surgery. The clinic works hard to get them ready. The clinic has a frailty scale that is used to identify a patient at higher risk.
• Hemoglobin A1c >8—this is the symptom exhibited by many obese and poorly controlled diabetics. “It’s not that the primary care physicians aren’t doing their job with these patients, it’s just that sometimes patients don’t get it or don’t want to own it. The clinic can strike while the iron is hot because these patients want to have a good outcome,” says Diez. “When they understand how their poorly controlled diabetes can make a difference, they’re ready to do something about it.”
• Smokers—patients are told about their pulmonary risks with surgery and that even short-term cessation can make a difference in their outcomes.
• Numerous comorbidities.
• Impaired skin integrity—some same-day procedures are cancelled because no one has asked patients if they have a skin rash.
• Poor dentition—clinicians try to identify poor dentition and have patients seen by a dentist preoperatively.
• Social/home issues—“we don’t want to send our patients home to places where they are unable to care for their new surgical wounds or don’t have the facilities to manage themselves,” says Diez.
• Cardiovascular/pulmonary issues.
Gently stir. After gathering the ingredients, gently stir them together, and then add:
• Point of contact—this is the referring surgeon’s office, and it is important to know who the communication person is in the office.
• Pending surgery date—patients are taken in the clinic with or without a surgery date. Those having elective surgery can postpone it to lose some weight or correct their blood sugar. “If we find a patient we feel really shouldn’t have surgery because of a preexisting condition, we reach out to the surgeon and discuss it,” says Diez. “The decision is still made by the surgeon and patient, but we give recommendations based on data.”
• Follow-up appointment—the clinic also schedules follow-up appointments so patients are seeing the surgeons who referred them to the clinic.
• Patient data/records—all the data on the patient is brought to the clinic before that person is seen there.
Bring to a simmer, stirring constantly. Gently fold in the primary care provider, and schedule the patient.
“We want to make sure the primary care providers know the patients are going to be seen in the clinic, and that the clinic isn’t trying to take their patients away from them,” Diez says. “It can get very territorial, and we don’t want that. We want collaborative work with everyone who is caring for the patient.”
It is after this that the patients are scheduled to come into the clinic.
Cook for 60 minutes. The patient comes to the clinic and has a 60-minute appointment, face-to-face with a nurse practitioner.
The nurse practitioner will:
• identify risk factors
• administer screening tools
• initiate treatment/further testing
• provide patient education
• make appropriate referrals.
Having already reviewed the patient’s chart, the nurse practitioner can comb through the history carefully and tease out other issues that haven’t been identified or addressed in the past, such as diabetes, atrial fibrillation, or heart murmurs.
Diez says that because of her endocrine background, she is comfortable with managing diabetics. In the clinic, she starts patients on insulin, adjusts their insulin, and then calls them to make sure they are managing their blood sugars.
She also makes adjustments to other medications until the patient is under control. “If I can get their sugars down before going to surgery, they’re going to have better outcomes in terms of postop infections,” she says.
After the clinic interview, Diez says, they provide a lot of education and motivational suggestions, and they make referrals if they have found a problem, such as cardiology for atrial fibrillation or a heart murmur.
The screening tools the clinic uses are:
• Alcohol Use Disorders Identification Test
• STOPBANG screening for sleep apnea
• Venous thromboembolism risk assessment
• Revised Goldman Cardiac Risk Index
• Frailty Score.
Remove from the oven. After the patients have been assessed, they leave the clinic. Diez communicates with the primary care provider, surgeon, specialist, anesthesiologist, and in-patient team. “I communicate back to everyone so they know what’s going on,” says Diez.
Apply icing. “Don’t underestimate the power of this step,” says Diez. “I don’t think it is the 1-hour appointment with me alone or the patient’s motivation alone that makes the difference. I think a lot of it has to do with what happens after they leave the clinic. If they are all pumped up when they leave the clinic, but when they get home they question whether they really have to do everything they were told, that doesn’t work.”
The patient care coordinators start calling the patients, evaluating their progress, and supporting them all the way to the day of surgery. They will see how they are doing with their smoking, weight loss, dentition, and other problems. If the patient is a diabetic, the patient care coordinators monitor their blood sugars, but Diez is the one who manages insulin changes.
The patient care coordinators also communicate the patients’ progress back to their primary care providers and to the surgeons to let them know how close the patient is to being ready for surgery. The patient care coordinators also make postoperative calls.
The end product is:
• reduced same-day cancellations
• reduced length of stay
• reduced surgical complications
• reduced 30-day readmissions
• significant savings.
Communication is the key, says Frank, to ensure that everyone involved in that patient’s care is aware of what’s going on in the clinic and with the patient.
Twelve months after the clinic opened, a comparison of clinic patients to all elective surgical patients found:
• a 2-day reduction in length of stay
• a 2% reduction in 30-day readmissions
• a 3% reduction in postoperative complications
• no mortalities
• no same-day surgery cancellations.
A comparison of clinic patients to all surgery patients with comorbidities showed:
• length of stay was cut in half
• 30-day readmissions were down about 2%
• postoperative complications were statistically significant nearly 17% less
• no mortalities
• no same-day surgery cancellations compared with 4.5% (sidebars above).
“Start small and grow big, and communicate your success,” advises Frank. “We started with orthopedics and slowly added others, like general surgery patients,” she says.
“The most rewarding thing has been that quite a few patients have come back to the clinic months after their surgeries so we can see how well they have done. They are so proud of what they have accomplished with our help.” she adds.✥
—Judith M. Mathias, MA, RN
Frank T M, Diez T. Reducing readmissions and cancellations for high-risk patients. OR Business Management Conference. 2018.