Pumped for pulmonary: A multidisciplinary team approach for targeting readmission risk, optimizing inpatient care, and anticipating discharge needs to mitigate readmissions in patients with chronic obstructive pulmonary

46^th Global Nursing & Healthcare

October 15-16, 2018 | Las Vegas, USA

Elena Ruocco

Houston Methodist Hospital, USA

Posters & Accepted Abstracts: Adv Practice Nurs

Abstract :

Frequent hospitalizations for COPD exacerbations are associated with poor prognosis and increased mortality. To address this, a multidisciplinary task force was formed to develop a multi-pronged approach designed to decrease future readmissions in this population. The group was comprised of a Physician, Nurse Practitioner, Respiratory Therapist, Pharmacist, Social worker, a Case Manager, and a Home Health Provider. The group met weekly and each specialist had a role in monitoring patients using a COPD standardized care plan. Evidence-based interventions were developed which started at admission and continued until discharge. The care plan was based on an average length of stay of five to seven days. Interventions included expert consultation with a pulmonologist, evidence-based diagnostics for the population, specific pharmacologic and medical treatments, physical therapy evaluation and treatment, assessment of nutritional needs, a psychosocial evaluation, tailored patient teaching, aggressive discharge planning, and a home care needs assessment. Readmission risk was calculated using a risk assessment model based on four criterion; the number of inpatient visits within the past six months, the number of unique medications started on hospital day one, insurance status, and the Rothman Index; a validated clinical tool that creates a composite number based on key nursing assessments, vital signs, and laboratory values which are predictors of deterioration and poor outcomes in the hospital setting. Those patients with a calculated readmission risk greater than 50% were placed on the standardized care plan. In a cohort of 400 patients between 2015 and 2017, the relative risk for readmission was reduced by 15% using the strategies outlined in the care plan.

Biography :

E-mail: elenaruocco@hotmail.com