No Return Trips: Hospitals Under Pressure to Lower Readmissions

Shmuel Shoham, MD


April 23, 2015

In This Article

Avoiding Readmissions Related to Infections

Many—perhaps even most—readmissions are unavoidable. The nature of progressive chronic illnesses is that they progress. Many conditions require therapies that increase the risks for infection. As patients age, they tend to become weaker, are more prone to serious infections, and have less reserves to deal with what would otherwise be mild infections that could be treated in the outpatient setting.

However, there are areas that can and should be addressed. Readmissions that result from infectious complications directly related to events occurring during the initial hospitalization, such as surgical-site and catheter-associated infections, often fall into the "preventable" category. Likewise, infections that result from poorly managed hand-offs between the inpatient and outpatient care teams are potentially preventable.

Ideas for reducing rehospitalization rates have included more frequent and earlier involvement of infectious diseases (ID) experts. Shrestha and colleagues[9] and Hamandi and colleagues[10] have reported that involvement of an ID specialist reduces rehospitalization rates in patients receiving community-based parenteral anti-infective therapy and solid-organ transplant recipients, respectively. Schmitt and colleagues[11] reported that involvement of an ID expert within 2 days of admission significantly reduced 30-day mortality and readmission rates for Medicare patients hospitalized with a serious infection (eg, bacteremia, osteomyelitis, or meningitis).

Table 3 details some of the approaches that are being used to reduce readmissions.

Table 3. Solutions to Reduce Readmissions

Timing Intervention
During hospitalization Meticulous attention to infection prevention practices with invasive procedures
Judicious use of indwelling catheters, sedation, and antimicrobials
Efforts to promote good nutrition, sleep hygiene, and mobility during hospitalization
At time of discharge Careful education of patient and caregivers about medications, prevention, and early recognition of infections and whom to follow up with after discharge
After discharge Facilitation of communication among patients, their caregivers, and the inpatient and outpatient clinicians

Just as there is no single cause for the posthospital syndrome and the increased risk for infection that it carries, there is no magic bullet that will eliminate this risk. Hansen and colleagues[12] reviewed dozens of studies in an attempt to find an evidence-based intervention to reduce readmissions. The studies described a range of interventions, including patient education, medication reconciliation, discharge planning, scheduling of a follow-up appointment before discharge, follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers, timely ambulatory provider follow-up, postdischarge home visits, transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instructions. The investigators found no strategy that was consistently effective when implemented as a solitary intervention. They also argued that the evidence base might not be adequate to facilitate change even for highly incentivized hospitals. At that time, penalties for "excessive" 30-day readmission rates were not yet being levied.

Others believe that readmission rates can be reduced with better communication strategies. Hesselink and colleagues[13] argues that hospital-based providers can reduce hospital readmission rates by providing high-quality discharge information that is understandable to patients and their caregivers, well-coordinated care, and direct and timely communication to their outpatient colleagues. Tools that are showing promise include discharge templates; medication reconciliation; a liaison nurse or pharmacist; and teach-backs, in which care providers check to see whether patients received and understood the discharge information.

In the current era, when hospitals have already been hit with heavy fines and many more are at risk, new and creative approaches including combinations of interventions are being implemented by hospitals, whose finances and reputations are on the line.


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