Healthcare systems today have embraced early readmissions—defined as admission within 30 days of discharge—as a valid metric for quality of care (JAMA Otolaryngol Head Neck Surg. July 23, 2015. doi:10.1001/jamaoto.2015.1323). Unplanned hospital readmissions are costly, can reflect poor quality index hospital care, and can lower patient quality of life, said Peter T. Dziegielewski, MD, assistant professor in the department of otolaryngology at the University of Florida in Gainesville.
In 2009, the Centers for Medicare and Medicaid Services began requiring hospitals to publically report their readmission rates and, in 2013, instituted financial penalties for medical facilities with 30-day readmissions that were associated with myocardial infarction, pneumonia, and heart failure. In 2015, the Hospital Readmissions Reduction Program (HRRP) of the Affordable Care Act expanded the scope to include surgical procedures.
Partnering with Community Physicians
In light of government standards and with ongoing efforts to improve quality of care, what are some best practices to reduce hospital readmission rates for otolaryngology patients?
Eric Genden, MD, chairman of the department of otolaryngology-head and neck surgery and director of the Head and Neck Institute at Mount Sinai Health System in New York City, advises perfecting care across the continuum. “The fact that academic centers and community physicians are two separate entities significantly contributes to readmissions,” he said. His center implemented three programs in the last seven years that have lowered readmission rates substantially. The programs strongly rely on the hospital’s relationship with community physicians.
Specifically, the center partnered with community otolaryngologists, including the largest otolaryngology community group in the country—ENT and Allergy Associates, with 40 locations in the New York tri-state area—along with radiation oncologists and medical oncologists.
“As part of these partnerships, we trained community physicians to screen and work up (e.g., perform a physical examination and medical history, radiographic assessment, and/or needle biopsy) on patients with head and neck cancers,” Dr. Genden said. “This expedited the diagnosis in the community and limited the cost of the workup because the appropriate tests are done the first time around as opposed to inappropriate testing and redundant testing.”
The center also partnered with community physicians on a same-day appointment process, so that patients with head and neck disease seen in the community could be transferred for therapy right away, which also expedites care. Community partners work with the hospital on surveillance protocols and post-therapy management when a patient has a minor or moderate complication. By enabling a patient to reach out to a community physician who can take care of a problem early in the process, problems can be better managed, and readmissions are prevented.
Developing partnerships with community groups required a new way of thinking, Dr. Genden said. For example, the treatment paradigm needed to extend beyond the academic center, because this should only amount to a small portion of time in the patient’s cycle of care. Most of the time, patients receive radiation chemotherapy and surveillance in the community. “By doing this, in addition to increasing communications with physicians, the patient receives better care that is much more cost effective,” he added.
The center also instituted the Patient First Program, in which a physician assistant or member of the nursing staff interviews every patient before he or she is seen at the cancer center to understand co-morbidities, social barriers, and financial barriers. Subsequently, these obstacles can be managed early on in the care process. Potential risk factors for readmission are identified and tackled.
A third approach involves the center forming hospital-wide readmission committees. These working groups are designed to identify patients at risk for readmission, including those with high-volume co-morbidities, those with highly complex diseases such as head and neck cancer, and patients who have less than ideal support at home and less than ideal access to community care, pinpointing patients who may have been missed in the Patient First Program process. The working group assigns these patients to community physicians and suggests community support resources to prevent them from being readmitted to the hospital.
In reviewing its readmissions, the Head and Neck Institute at Mount Sinai Health System determined that approximately 80% could have been avoided if problems had been managed in the community earlier in the process. Combining the three approaches has decreased the number of hospital visits from 2.7 to 1.3 per patient, largely because much of the workup and evaluation is coordinated with the patient before a visit, Dr. Genden said.
Using a Pre-Admission Clinic
Dr. Dziegielewski believes that preventing hospital readmissions begins with the decision for surgery and continues through the hospital stay and the post-discharge period. “By having patients attend a pre-admission clinic, readmissions can potentially be prevented,” he said. In fact, a study by Dr. Dziegielewski and his colleagues showed that patients who did not attend a pre-operative clinic had an eight-fold greater chance of a 30-day readmission (Head Neck. Mar 9, 2015. doi: 10.1002/hed.24030).
“The clinic performs a battery of baseline laboratory and imaging tests to screen patients for correctable issues before surgery,” he said. “It also directs patients to appropriate medical subspecialists for optimization of chronic medical conditions during the perioperative period.” The clinic also employs an anesthesia team member who plans ahead for complex procedures, such as a free-flap case.
Taking this a step further, the University of Florida has instituted a multidisciplinary pre-operative day for head and neck surgery patients. They attend pre-admission visits with the anesthesia clinic, speech language pathologists, dietician, dentistry, G-tube tube clinic (if warranted), and internal medicine clinic.
Addressing Quality Care
The University of Florida addresses quality care on multiple fronts, as part of its effort to prevent readmissions. Patient and caregiver satisfaction are evaluated during the hospital stay. “This is gauged with surveys or weekly quality rounds led by the physician team,” Dr. Dziegielewski said. “Areas of concern are recorded and acted upon to improve the patient/caregiver hospital experience.”
In addition, the hospital has set a goal of improving communication between the patient and care team. Simple interventions, such as placing a white board in front of a patient’s bed listing the care team members and their roles, any upcoming tests, and the patient’s daily goals, help patients to better understand their care.
Improving discharge planning and education is another priority. “Ensuring that patients and caregivers are capable of taking care of wounds, tracheostomy sites, laryngectomy stoma sites, and G-tube sites via nursing demonstrations, videos, and instructional pamphlets is important,” Dr. Dziegielewski said.
Patients or caregivers must demonstrate proper wound care procedures, as well as airway and tube feed care techniques to the nursing team prior to discharge.
Following discharge, patients are given coordinated follow-up appointments with their surgeon and appropriate ancillary health staff, such as physical therapists and speech language pathologists. Patients are called within 72 hours of discharge to monitor at-home recovery and confirm follow-up appointments. If a patient fails to attend follow-up visits, a clinic nurse will call.
Preventing Surgical Site Infections
While the percentage is low among otolaryngology surgical patients (0.06%), surgical site infection (SSI) was the most common predictor for readmission found in a study by Jain and colleagues, reported Stephanie Shintani Smith, MD, MS, assistant professor of otolaryngology-head and neck surgery at Northwestern University Feinberg School of Medicine in Chicago, and a co-author of the study (Laryngoscope. 2014;124:1783-1788). SSIs account for more than $3 billion (and up to $10 billion) in direct costs annually, according to the CDC. “Several best practice guidelines exist to help prevent SSIs,” Dr. Smith said. “They focus on appropriate timing, selection, and duration of prophylactic antimicrobial agents.
Providing Good Coverage
In private practice, physicians who cover for other physicians must have the skills to manage their patients and should have a full understanding of the patients and their individual problems, said Virginia Feldman, MD, attending physician at Orange Regional Medical Center and ENT and Allergy, both in Middletown, N.Y., and founder and CEO of Nexus Health Resources, a Middletown care management company that assists hospitals and skilled nursing facilities in reducing avoidable hospital readmissions. For complex cases, the covering surgeon must be able to reach the admitting or operating surgeon. “By having the operating surgeon answer specific questions directly, the covering physician may be able to better understand the patient’s clinical condition—as well as his needs and nuances that he may otherwise overlook,” she said.
For example, a physician may have the skills to do a thyroidectomy, but a particular patient may have special needs. “It is customary to provide a ‘sign-out’ to the doctor covering the call, but this best practice is not always carried out, even though it is essential to providing good care during nights and weekends when a problem may arise,” Dr. Feldman said. “Without knowing the patient, the physician on call may instruct the patient to go to the emergency room. But by having a working knowledge of the patient, the physician on call may be able to offer instructions over the phone or provide care instructions to emergency room staff.”
Additionally, having evening and weekend office hours increases patient access to physicians, Dr. Feldman continued. Otherwise, a patient may have to seek treatment at an emergency room.
Another suggestion is to involve more senior and experienced surgeons for high-risk patients. “These doctors may be better suited to manage surgical procedures and recognize potential complications early on,” said Lifei Guo, MD, PhD, chairman of the department of plastic and reconstructive surgery at Lahey Hospital and Medical Center in Burlington, Mass., a teaching affiliate of Tufts University School of Medicine in Boston, where he is an associate professor of surgery.
Many best practices can be employed to prevent otolaryngology patients from returning to the hospital. Among these are partnering with community physicians, using a pre-admission clinic, addressing quality care, preventing SSIs, providing good physician coverage, and involving experienced surgeons more closely in high-risk cases.
Karen Appold is a freelance medical writer based in Pennsylvania.