RNs at Newton-Wellesley Hospital are working to keep discharged patients from unnecessarily returning to their hospital beds.
Better education about post-discharge care, making sure staff is aware of all medications before a patient leaves and checking in with patients after their stays are among the strategies the Newton, Mass., facility is using to reduce avoidable readmissions.6 East team members, from left, are: Cheryl Bardetti, RN, STAAR day-to-day leader; Irene Ryan, RN, nurse educator; Janet Stinehart, RN, nurse manager; Margaret Burke, RN, permanent charge nurse; and Leigh Remington, RN, permanent charge nurse.
Newton-Wellesley began participating in the Institute for Healthcare Improvements State Action on Avoidable Readmissions initiative in September 2009. The project is being piloted on two units at the facility, including a medical unit where heart failure patients are being targeted, and an orthopedic surgical floor.
If you come to the hospital and your discharge diagnosis is congestive heart failure, and within 30 days you come back to the hospital again with that same diagnosis, our question is, could we have possibly avoided you coming back? says Cheryl Bardetti, RN, BSN, quality and safety RN specialist and STAAR day-to-day leader at Newton-Wellesley. We want to make sure weve covered all the elements.4 Usen team members, from left, are: Andrea Elliott, RN, case manager; Sharon Keogh, RN, staff nurse; Janet OConnor, RN, permanent charge nurse; Christine Gaggin, RN, nurse educator; Deborah Phillips, RN, nurse manager; and (not pictured) staff nurse Christine Lydon, RN.
Those elements include providing patients education and information about their care before surgery, rather than after when they might be groggy or distracted. RNs also review information with patients using teach-back methodology throughout their stays to ensure they understand what to do at home, Bardetti says.
In July, the hospital teamed with Partners Home Care to pair heart failure patients with visiting nurses who come to their homes and closely monitor them with a defined protocol, Bardetti says.
RNs also keep track of discharged heart failure patients through telemonitoring, which allows nurses to monitor vital signs from an office while the patients are at home. Patients also receive follow-up calls within a week of their discharge, a program started about nine months ago.
Its very eye opening to hear what patients are saying when they get home, Bardetti says. You get a sense of how theyre doing at home. Were giving you all this information to take home. Were finding the discharge phone calls highlight and review that information.
A hospital-based Heart Failure Clinic that allows heart failure patients to receive treatment on an outpatient basis also is helping to reduce readmissions, Bardetti says.
Nurses also make sure patients have a designated support person identified on admission available during their recovery, whether it is family, a neighbor or friend who can assist with discharge instructions and care. For patients who have trouble pursuing follow-up care because of finances, transportation issues or living alone, Newton-Wellesley provides nurse case managers.