Watch Out 30 Day Readmissions are Avoidable for Stroke Patients – Startling News Requires Action

By Lynn Razzano, RN, MSN, ONCC

A recently published study, December 2013, on preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries looked at the proportion of post stroke readmissions that are potentially preventable or avoidable. This continues to remain unknown.  Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated.

The findings based on the prevention quality indicators identified a small proportion of readmissions were classified as preventable. Clearly more research needs to be conducted in this area but the clinical significance, in the interim, is hospital level programs should reduce all-cause readmissions and costs should target high risk patients. Intensive work need to be done in how best to clinically identify the high risk patient criteria and develop a workable process, safety checklist, and protocol to identify the patient and interventions to prevent avoidable readmissions in the stroke patient population

The implications of this study are clear –  A call to action we should all be aware of and advocate stopping VTE in its tracks to reduce and preventis 30-day readmissions for stroke patients. We need to be on a vigilant watch on the warning signs of possible readmissions in the stroke patient. These patients face clinical challenges as well as mobility and functional hurdles that are next to none in terms of high-risk patient populations. We need to ask ourselves what are we maximally doing to prevent these and are there any ensuing signs that the stroke patient may be in a risk state for re admission.

The costs to our healthcare system we operate in daily are staggering for readmissions and I use VTE which is preventable and deemed a “never event “as the example. If the patient has just been recently discharged and medically complex they may be likely to be readmitted, having a recent hospitalization places patients at a higher risk for VTE development. In terms of the stroke patient this is even high due to insufficient ability to be mobile and ambulatory to the point that it would aid in VTE prevention.

This recent study is consistent with previous research on this same issue.

In a 2010 study published in Stroke, researchers found that almost two-thirds of Medicare beneficiaries discharged from hospital after an ischemic stroke die or are readmitted within a year. We still have considered, as well, those patients that have hemorrhagic stroke, Cerebral Vascular Disease and neurologically compromised disorders. The problem is indeed challenging and the volume of patients affected continue to grow so an answer is needed to provide the clinical guidance we should assess at time of discharge and transition to home or post-acute setting. There are many clinical stakeholders that should have a committed interest in developing a readmission checklist that could be used to baseline assess the patient before discharge.

The 2010 study also showed that these post discharge death and rehospitalization rates varied considerably among hospitals. Although academic hospitals and those in the Northeast and West had slightly more favorable outcomes, the size of an institution or its stroke center designation did not make much of a difference in terms of mortality and readmission rates.

“The very high rates of death and rehospitalization are in a sense staggering, and despite some advances, stroke continues to place a burden on this patient population, which is fee-for-service Medicare beneficiaries,” said lead study author Gregg C. Fonarow, MD, professor of cardiovascular medicine at the University of California at Los Angeles and associate chief of the Division of Cardiology at the David Geffen School of Medicine. “Also striking is the very substantial variation in clinical outcomes by hospitals”

What is the current impact of stroke in our health care system currently? Stroke is a major cause of hospitalization in the elderly individuals and is estimated to affect about 800,000 people per year in the United States.     

This number will continue to grow in volume due to the increasing numbers of “baby boomers” that may have significant risk factors for stroke, medically complex and chronic conditions, and repeated hospitalizations for stabilization of medical condition. For this fact and often readmission are avoidable in the stroke patient population, it is clinically significant to identify those factors that place the stroke patient at an escalated risk for re admission and re hospitalization post discharge.

In my clinical experience and through researching this topic to validate what I found to be in my clinical practice are the precursors/trigger factors to readmission in the stroke patient population are the following:

  • Hospitalization length of stay greater than 10 days
  • Medically complex or chronic conditions that may not have been well managed-in particular Congestive Heart Failure (CHF) and Cerebral Vascular Disease (CVD)
  • Readmitted within 30 days for elective procedures(medical and surgical) that were not well coordinated
  • Readmitted due to lack or inadequate outpatient care coordination. This could be eliminated if  follow up appointments would occur within 5-7 days of discharge or patient’s should be assigned a discharge coach, provided assistance with transportation to appointments/outpatient testing.
  • Readmitted due to lack of completed initial evaluation and stabilization. Inadequate evaluation and documentation would also be included in this trigger
  • Readmitted due to delay in palliative care consultation, coordination and or treatment which was necessary for the patient.
  • Readmitted after discharge due to inadequate or ill-defined discharge instructions that resulted from insufficient well-coordinated discharge instructions. This should be communicated to the patient, caregiver, significant other(s), the next transition of care facility i.e. rehabilitation and the patient’s PCP.
  • Potential for VTE development due to high risk factors for stroke patients and the fact of an readmission reoccurring within 30 days of discharge. The patient should be assessed prior to discharge for any VTE RFA and VTE prevention including anticoagulation and mechanical IPC should be ordered post discharge for home care VTE prevention.

In researching this topic for current successful ideas for preventing readmission for patients with complex medical conditions such as stroke I located one that has been trialed and appears novel with a unique approach to preventing readmissions. Louisiana Health Care Review lowered readmissions rates by 80 percent with care transition coaches:

The program works by pairing older patients with a “transition coach.” The patient agrees to meet with the coach within 48 hours of discharge and the coach helps the individual put together a list of questions for their primary care physician. Transition coach and patient teams also discuss questions about medications and devise a self-care plan after leaving the hospital, among other collaborative measures.

In conclusion, I think well-developed clinical recommendations that identify the factors that precipitate a readmission within 30 days for the stroke patient can promote patient safety, quality and lessen the associated economic costs that go hand in hand with a readmission to the hospital pot discharge. I think strong critical evaluation of current practice standards in your respective Stroke centers would benefit significantly in preventing avoidable readmissions. Use of patient safety checklists and engagement of the patient along with education goes a long way and has been proven highly successful in preventing adverse events and unnecessary hospitalization.

I hope this article has provided clinical insight into a significant problem we now face as two thirds of Medicare beneficiaries discharged from a hospital after an ischemic stroke die or are readmitted within one year, a new study has found. We can certainly change this type of statistics with updating our current practice, utilizing readmission trigger checklists and provide the comprehensive discharge planning, engagement and care coordination that is identifiably needed for this patient population.

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