Error loading player: No playable sources found
Decreasing Hospital Re-Admission by Utilizing an Enhanced TOC Bundle
Background and significance: Sepsis is the body’s overwhelming, life-threatening response to infection, this can lead to organ failure and death. 60% of hospital readmissions occur within thirteen days of discharge. In CY2019, Michigan Medicine’s sepsis population had a 30-day all-cause readmission rate of 22%. In 2020, the Michigan Medicine clinical design and innovation (CDI) team with nurse care navigators (CNs) and TOC pharmacists, partnered to review data surrounding sepsis patients and hospital readmission to create a sepsis TOC model. The sepsis TOC model utilizes embedded nurse CNs to provide additional TOC calls specific to patients discharged following a sepsis diagnosis. Transition of care (TOC) is defined by any movement of a patient from one setting of care to another.
Goals: The goal of this project was to decrease the all-cause readmission rate from 22% to 21% by enhancing the existing TOC service.
Methods and evaluation: The sepsis TOC team assembled in September 2020. Sepsis (post-sepsis syndrome) M-learning was amended to serve outpatient clinical staff.
On 6/16/2021, the sepsis TOC bundle went live for discharged patients with a MM PCP. Patients were contacted within 2 business days, then referred to embedded CN for additional follow-up, with weekly contact for 4 weeks and assessment for longitudinal support. They were contacted by a PharmD within 3-5 business days and given a 5-question survey. On 10/5/21, the process for discharged patients with an external PCP went live. These patients were referred to the patient monitoring at-home program.
Result: Data collected from 1/1/2021 to 12/12/2021 revealed pre-pilot readmission rate of 22.09%, whereas pilot readmission rate of 19.86%. Data collected from 6/16/2021 to 12/12/2021 revealed not-in-pilot readmission rate of 21.03% whereas in-pilot readmission rate was 19.86%.
Significance/conclusion: This new process did not impact the workload of the CNs. The impact this new process has on reducing hospital re-admissions was extremely successful.
Summary: The sepsis TOC bundle pilot was successful at decreasing readmission rates of sepsis patients by providing enhanced follow-up with TOC pharmacist and embedded nurse CNs.
Goals: The goal of this project was to decrease the all-cause readmission rate from 22% to 21% by enhancing the existing TOC service.
Methods and evaluation: The sepsis TOC team assembled in September 2020. Sepsis (post-sepsis syndrome) M-learning was amended to serve outpatient clinical staff.
On 6/16/2021, the sepsis TOC bundle went live for discharged patients with a MM PCP. Patients were contacted within 2 business days, then referred to embedded CN for additional follow-up, with weekly contact for 4 weeks and assessment for longitudinal support. They were contacted by a PharmD within 3-5 business days and given a 5-question survey. On 10/5/21, the process for discharged patients with an external PCP went live. These patients were referred to the patient monitoring at-home program.
Result: Data collected from 1/1/2021 to 12/12/2021 revealed pre-pilot readmission rate of 22.09%, whereas pilot readmission rate of 19.86%. Data collected from 6/16/2021 to 12/12/2021 revealed not-in-pilot readmission rate of 21.03% whereas in-pilot readmission rate was 19.86%.
Significance/conclusion: This new process did not impact the workload of the CNs. The impact this new process has on reducing hospital re-admissions was extremely successful.
Summary: The sepsis TOC bundle pilot was successful at decreasing readmission rates of sepsis patients by providing enhanced follow-up with TOC pharmacist and embedded nurse CNs.
Learning Objective
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Speaker
Amanda York, BSN, RN
General
Related Products
The Institution of a Standardized Telephone Triage Course
Purpose: Within our ambulatory primary care clinics, planning for the ever-changing needs of our patients and communities is a priority of leadership and clinical education. Ambulatory care telephone triage is one of the organization's most rapidly growing and changing specialties…
Development of Clinical Inbox Report Allows for Data-Driven Decision-Making
Patients within a large midwestern multi-site ambulatory primary care practice group are connecting with their healthcare providers and the ambulatory patient care team at record-breaking levels outside of the traditional provider appointment visit…
The PACT Hub of Excellence (PHE), Reinvigorating the PACT Model Concept of Patient Care Post-Pandemic
We all know the effects of the pandemic. The PACT (patient-aligned care team) model for patient care became “diseased.” Accessing care became limited due to CDC (Centers for Disease Control) workplace guidance and recommendations…
Improving Quality of Care for Hypertensive Patients across Seven States through a Competition-Based and Micro-Learning Education Initiative
Purpose: The purpose of this initiative is to improve the quality of care for patients with hypertension by enhancing clinical staff knowledge of blood pressure measurement technique, increasing awareness of the quality metric for hypertension, and implementing a standardized protocol for repeat me…
