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.