Ogunwole Serena Michelle, Phillips Jason, Gossett Amber, Downs John Richard
Internal Medicine, University of Texas Health Science Center, San Antonio, Texas, USA.
Department of Cardiology, South Texas Veterans Health Care System, University of Texas Health Science Center, San Antonio, Texas, USA.
BMJ Open Qual. 2019 Jan 14;8(1):e000386. doi: 10.1136/bmjoq-2018-000386. eCollection 2019.
Despite improvements in length of stay and mortality, congestive heart failure (CHF) remains the most common cause of 30-day readmissions to the hospital. Though multiple studies have found that early follow-up after discharge (eg, within 7 days) is critical to improving 30-day readmissions, implementation strategies are challenging in resource-limited settings. Here we present a quality improvement initiative aimed at improving early follow-up while maximising available resources.
This was a medical resident-driven initiative. A process map of the discharge and follow-up appointment process was created that identified multiple areas for improvement. Based on these findings, a two-part intervention was implemented. First, heart failure discharge education with focus on early follow-up was disseminated to providers throughout the internal medicine department. Subsequently, improved identification of high-risk patients (ailure ntervention isk tratificationool) and innovative use of the existing electronic medical record (EMR) were employed to sustain and improve on gains from the first set of interventions.
We increased our 7-day follow-up rate from 47% to 57% (p=0.429) and decreased the average time to follow-up from 17.6 days to 8.7 days (p=0.016) following the first intervention. The percentage of patients readmitted within 30 days after discharge at baseline (2012-2013) and following the first intervention (education and standardisation of follow-up scheduling) and second intervention (risk stratification, intensive follow-up and EMR change) was 25% and 21%, respectively. Thirty-day mortality rate decreased from 10% in 2011 to 7.16% in December 2015.
Close hospital discharge follow-up and identification of high-risk patients with CHF are useful approaches to reduce readmissions. Using the existing EMR tool for identifying high-risk patients and improving adherence to best practices is an effective intervention. In patients with CHF these strategies improved time to follow-up and 30-day readmissions while decreasing mortality.
尽管住院时间和死亡率有所改善，但充血性心力衰竭（CHF）仍是患者出院后30天内再次入院的最常见原因。多项研究发现，出院后的早期随访（如7天内）对于降低30天再入院率至关重要，但在资源有限的环境中，实施策略具有挑战性。在此，我们提出一项质量改进计划，旨在改善早期随访并最大限度地利用现有资源。
这是一项由住院医师推动的计划。绘制了出院和随访预约流程的流程图，确定了多个需要改进的领域。基于这些发现，实施了两部分干预措施。首先，向整个内科部门的医护人员开展了以早期随访为重点的心力衰竭出院教育。随后，采用改进的高危患者识别（心力衰竭干预风险分层工具）和对现有电子病历（EMR）的创新使用，以维持并改善第一组干预措施所取得的成效。
在首次干预后，我们将7天随访率从47%提高到了57%（p = 0.429），并将平均随访时间从17.6天缩短至8.7天（p = 0.016）。基线期（2012 - 2013年）、首次干预（随访安排的教育和标准化）以及第二次干预（风险分层、强化随访和电子病历变更）后出院30天内再次入院的患者百分比分别为25%和21%。30天死亡率从2011年的10%降至2015年12月的7.16%。
出院后密切随访以及识别CHF高危患者是降低再入院率的有效方法。利用现有的电子病历工具识别高危患者并提高对最佳实践的依从性是一种有效的干预措施。对于CHF患者，这些策略缩短了随访时间，降低了30天再入院率，同时降低了死亡率。
