P0153 - Successful Implementation of a Discharge Bundle to Reduce Unplanned 30-day Readmissions: Lessons Learned

Introduction: Elevated unplanned readmission rates (URR) may be a reflection of poor discharge transition practices. To address this, Solutions for Patient Safety (SPS) promotes a five element discharge transition bundle; however barriers participant hospitals may encounter and strategies for successful implementation have not been fully described.

Objective: 1) Decrease the rate of 30-day URR by 10% within 12 months.

Methods: This project was conducted at a 433-bed, tertiary care, non-profit freestanding children’s hospital with about 18,400 annual discharges. Planned readmissions for procedures, chemotherapy, as well as rehabilitation and psychiatric readmissions were excluded. Using quality improvement methodology, a multidisciplinary group implemented SPS bundle elements from 7/1/2017-6/30/2018 in variable order. Interventions included: 1) Schedule subspecialty follow-up appointments before discharge; 2) Intensive discharge planning of high-risk populations; 3) Post-discharge phone call within 72-hours to reinforce discharge instructions; 4) Specific anticipatory guidance imbedded in the discharge instructions; 5) Provider notification of 30-day readmission.

Results: 30-day URR decreased by 19% (from 8.2% to 6.6%) following implementation of five bundle elements (Figure 1). Barriers to each intervention and lessons learned are outlined (Table 1). Decrease in URR was not achieved until after implementation of element one (scheduling follow-up appointments). Introduction of disease specific discharge instructions (element four) may have helped to sustain change. Element three (follow-up phone calls) was the most difficult to enact. A year after the implementation of the SPS bundle, the 30-day URR has been sustained.

Discussion/

Conclusion: Institution of a comprehensive discharge bundle at a large children’s hospital was successful in decreasing the URR. Major barriers included lack of financial incentive to the organization which limited available funds for tasks requiring additional staff (element three; follow-up phone calls). Hospital administration support was a powerful tool in adjusting subspecialty post-discharge appointment availability thereby optimizing the discharge transition. Effective modification of the electronic medical record was important both in streamlining documentation of patient instructions and ensuring follow-up appointments were made prior to discharge. Buy-in from providers was important throughout and modifications were required to ensure ongoing active engagement. Ongoing monitoring of URR will continue at our institution.