Discharge From a Crowded Hospital Ward Ups Readmission Risk

Ingrid Hein

May 21, 2018

Patients discharged from crowded hospital wards are more likely to be readmitted to the hospital in the subsequent 30 days, new data show.

The three strongest predictors of a patient's readmission "are all modifiable, ward-level factors," said lead researcher Rachel Kohn, MD, from the University of Pennsylvania in Philadelphia

These are the number of patients discharged on the same day, the number of medications administered to all patients on the ward on that day, and the number of patients that occupied a bed that day, she reported at the American Thoracic Society 2018 International Conference in San Diego.

Our theory is that, when there is more work to do, discharge planning is being neglected or not being done as thoroughly as it could be, Kohn told Medscape Medical News.

"Ward capacity strain is a novel construct," she added. Previous researchers have looked at individual items that affect critical care response, but not much work has been done to find predictors.

When one ward performs and another doesn't, we need to look closely at the differences, she explained.

To evaluate readmissions, Kohn and her colleagues looked at discharges from the intensive care units — 33 wards — of three Pennsylvania hospitals in 2014 and 2015.

For each of the 13,338 patients, they examined hospital capacity on the last calendar day of their hospital stay. Capacity was assessed by looking at how many beds were filled, how many medications were administered, how many patients were transported off the ward, and how many patients required telemetry monitoring, transfusions, or a sepsis assessment.

When the team analyzed the data, three top factors from nine hospital wards emerged as predictors of readmission in the subsequent 30 days.

When a lot of people are being discharged on a specific day, it means a lot will be coming back.

But there was one key factor: "When a lot of people are being discharged on a specific day, it means a lot will be coming back," said Kohn.

When the ward is busy, discharge paperwork and medication checks might not be done as well as they should be. "The more work you're imposing on staff, the more things can be missed," she noted.

This might seem obvious, Kohn acknowledged, but nobody has really defined ward capacity strain.

Capacity strain has been studied in intensive care units and emergency departments, but these are easier units to look at. "You have one small physical space, so it's easier to capture everything going on. When you start talking about wards, it's a much larger portion of the hospital," she said.

But wards are where the majority of patients reside, and changes there could have a substantial impact, she added.

Targeting Change

To get a sense of changes that should happen at the ward level, a lot of qualitative work — talking to ward-based clinicians, case managers, and social workers — must be undertaken.

"We need to develop a better understanding of the underlying mechanisms," Kohn said. Our predictors "are just markers."

"We need to look closely at where we might be able to intervene," she added. For example, if members of the staff are consistently overburdened by medication administration, a workload threshold can be set that, when reached, prompts the addition of staff.

Changes to discharge practices might also help. Having a dedicated nurse in charge of transportation, paperwork, and medication could alleviate the burden on nurses actively caring for other patients, Kohn suggested.

This is just the beginning of our work. "Now we have to figure out how to move forward," she told Medscape Medical News. "I'm hopeful that this will lead to ward-level and hospital-level systems practice changes that will impact survivors of critical illness."

Slow Medicine

"Slow medicine" could be the key to recovery after discharge from the intensive care unit, Victoria Sweet, MD, from the UCSF School of Medicine in San Francisco, said during her keynote address.

Hospitals use an assembly-line approach, but we need to take the time to examine our patients and talk to them, she explained.

Helping a patient get better involves two things, Sweet told Medscape Medical News. "First, we have to start with the body: what happened before they got to the ICU, during their visit, and after. Second, find out what's in the way of the patient getting better, instead of 'repairing' them."

A starting point is the assessment of a patient's medications and the elimination of unnecessary drugs. "I have found that often when patients are on 15 to 20 medications, they really only need five of them," she said.

Next, the development of better follow-up practices could help, she explained, adding that a system in which hospital doctors follow their patients after discharge might make a difference.

"Focus on the top people likely to be readmitted and send them to the clinic to see the same doctor a few days later," Sweet suggested. "Are they getting better or do they have a bladder infection?"

When you're forced to discharge a patient who's not ready, you have moral distress.

"We need to give patients a good doctor who has the time to do a good job," she said.

At the hospital in California where she worked for years, Sweet said she had the "luxury" of seeing a patient more than once.

And watching somebody get better can contribute to the elimination of burnout, she added.

In fact, "it's not burnout. It's moral distress. "When you're forced to discharge a patient who's not ready, you have moral distress. We need a perspective change," she said.

Kohn and Sweet have disclosed no relevant financial relationships.

American Thoracic Society (ATS) 2018 International Conference: Abstract P288. Presented May 20, 2018.

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