Nurses devise tool to reduce hospital readmissions

By | 2021-05-07T17:30:01-04:00 December 23rd, 2015|5 Comments

While hospitals across the country are looking for new ways to bring readmission rates down, nurses at California Hospital Medical Center in Los Angeles have developed a new tool to reduce hospital readmissions.


Gladys G_Castro_SNIPCastro, RN

“We were looking for a way to improve on our generic readmission checklist that is completed on a patient’s admission to the hospital,” said Gladys Castro, RN, nurse manager on the med/surgical unit at California Hospital Medical Center. “The med/surgical unit has the highest volume of readmissions, so we formed a committee to develop a tool that would identify risk factors for patient readmission.”

Within two weeks the committee had developed the high risk readmission form, which is filled out upon a patient’s admission to the hospital. It includes questions that assess each patient’s mobility, risk of falls, whether they use oxygen, age and other factors. If a patient is identified as being high risk, then the admitting nurse will put in an order for a case manager to review the case.

“Our goal was to determine why patients were being readmitted to the hospital,” Castro said. “We wanted to identify obstacles such as oxygen that might not have been ordered early enough, or patients not having an adequate discharge destination where they would receive proper care.”

Identifying those at risk

Castro and her colleagues hoped to develop a tool that could easily be adapted for use in discharge planning to predict a patient’s risk of future hospital readmission.

The committee at California Hospital Medical Center found patients with chronic diseases such as asthma, diabetes, and heart failure were being readmitted within 30 days of their discharge, with congestive heart failure being one of the highest causes for readmission.

“We looked at the readmission metrics from quality and started to drill down to identify the discharge and admission diagnosis,” Castro said. “Using the new tool, the case manager and the nurses work collaboratively with the patient to prevent readmissions.”

Promising results

While it has only been a over a year since the high risk readmission form was introduced, Castro said it’s shown promising results.

“We haven’t eliminated readmissions entirely, but we have shown a significant decrease,” Castro said.

“In addition, we’re seeing that the form is engaging staff to become agents of change. They understand the form isn’t just another piece of paper to fill out.”

Castro said the form has been tweaked twice due to staff suggestions, and that the hospital has seen staff compliance rise from 33% when the form was first introduced to 98% compliance.

The committee is looking at other ways readmissions can be reduced, such as assigning nurses to call patients after they have been discharged to answer any questions or concerns they might have, to ensure that each patient has received adequate education upon discharge regarding how to manage their condition and when to take medication.

“We’re also looking at patients who may be homeless and how we can connect them with community resources after their discharge to ensure they receive continued care,” Castro said.

The high risk readmission form also is used during the med/surg staff’s morning huddles to address any issues or problems that may have surfaced since a patient was first admitted.

“As part of our commitment to patient-centered care, we are using the form to look at what the patients need upon admission to the hospital whether it’s chronic disease education, oxygen or help getting to their appointments or getting their medications filled,” Castro said.

Since the California Hospital Medical Center serves a diverse population, Castro said staff is required to use telephone interpreters, rather than rely on a patient’s family to translate information.

“Our nurses do a fantastic job and we’re always looking for ways to recognize their efforts,” Castro said. “We have a regular Med-Surg Angel award that is driven by patient thank-you notes and a teambuilding program where nurses are encouraged to thank their colleagues for their support and teamwork.”


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About the Author:

Linda Childers is a freelance writer.


  1. Avatar
    Tonya Todd December 23, 2015 at 4:37 pm - Reply

    Med/Surgical unit is a very difficult unit because of end stage chronic illnesses and new onset. The nurses who work this unit are expected to know a great deal concerning all. The amount of drugs to be given that need to be checked and keeping up with labs is mind blowing. Nurses on this unit usually have more patients. There are 2 and 3 discharges and admissions for each of these nurses most times. Another form to fill out by nurses is what is needed? No disrespect but middle management requires projects like this to be done. A very few are valid. This level of nursing needs to create “numbers,” that higher executives can report to the corporation which owns hospital. Today hospitals are businesses which are only concern about “numbers,” in which their main goal is profit. The most reimbursement they can receive from each patient increases profit. I’ve been ordered many times to go to units and get “numbers,” which reflect how long patients have been there, find out why, and if “they,”have crossed over the “highest reimbursement line.” I have had to get directors of the unit jumping to empty beds for quicker admissions. I have had to question social workers why they have not fulfilled discharges by not getting the possible resources for patients that could have been discharged 2 days ago. (You know those social workers, and all their coffee breaks!) The NURSES! whining all the time about the patient/nurse ratios. Yes let’s give them form after form to fill out for each patient….oh wait, the hospitals have been doing that for years! The amount of paperwork alone should have studies. Our regulating state officials should support nurses and patients more. The mountain of paperwork should be one of their main focuses to reduce, for better and safer healthcare and there is a direct correlation of nonsense unnecessary paper work but that is a study that will never be approved. When I was a younger nurse, I started keeping a timeline of how many minutes it took for all expected paperwork to be completed and I would include time it usually takes one or two discharges followed immediately by admissions. Giving drugs, check recheck orders, labs, calling doctors, getting patients ready for procedures you know day to day actual patient care. I averaged out minutes needed to fulfill these requirements. (so many other things unexpected not included in my study which I didn’t assign minutes to but made the most comprehensive list of, to also submit) In a 12 hour work day, the “numbers,” showed I needed at least 6 hours of minutes! I had a couple close nurse friends to check me. They took it home, they took this very seriously, when they got back with me, their numbers were within a 2 hour window to mine. I finalized this report and gave it to my supervisor. Within 4 hours, I was called to the Director of Nurses office. Let’s just say, it wasn’t pretty! Bottom line…this was a unauthorized study, how many copies of the report were made, who saw the data and so forth. I was written up and it included , what she called infractions of the hospital and I was to sign this incident report. I quietly with respect asked her for all the policies that supported the “infractions.” There were not any policies in place at that time which could support her data. I think you understand this comment. It is something nurses, doctors understand, get the patients OUT before reimbursements start decreasing on each patient. So the nurse do not need another form. Patients are discharged too early, it is plain simple. I would love to see studies of “minutes,” needed to give quality healthcare posted. This more than any thing will create havoc in the corporations which owns hospitals, nurses and now trending doctors. The most important thing that suffers from all this nonsense….THE PATIENT. Love on your patients today, they are frightened.

    • Avatar
      BJW December 27, 2015 at 5:03 pm - Reply

      Couldn’t have said it better myself. Nurses don’t need another form to fill out. The need for timely and effective collaboration with the healthcare team, proper and timely patient follow up after discharge, and effectively educating the patient and caregiver before discharge are paramount in helping to prevent readmissions. Yet, nothing is guaranteed, as the myriad variables that influence an outcome are inevitable and difficult to control, especially in chronic disease management. The real bottom line is the budget and how to make money, not lose it. Hospitals are corporate indices whose aim is to protect patients, improve care and quality of care, while meeting profit margins. Case managers are overloaded and burdened by lack of resources and care giver follow up, while being pressured by “the numbers game” to discharge patients prematurely. Ultimately, a readmission within 30 days will occur. I do concur that having a team of nurses make follow up calls to discharged patients to answer questions or concerns is a terrific concept and I would promote it as long as there is adequate compensation for the nurses’ time and efforts. I believe more case managers are needed to fulfill this follow up role, frankly. Inpatient nurses have enough on their shoulders in a 12-HR shift!

      • Avatar
        KAA December 30, 2015 at 3:55 pm - Reply

        This is a fabulously true to the core article and patient care quality is brushed under the rug for the almighty dollar.
        Healthcare in America is NOT getting better, but the truth hurts sometimes and these wonderful nurses who dedicate their life to see patients and families through this scary process of illness should never be shunned while trying to make their job easier (because apparently the upper ivory tower doesn’t) to see the patient through and do the best they can so the patient is not re-admitted, helps everyone all around.
        Dig deep, re-do policies, it’s not always about money & please remember the human compassion factor here !!! This will be us, our parents, grandparents, or friends one day!

    • Avatar
      Gladys Castro January 1, 2016 at 4:49 am - Reply

      It’s unfortunate you were written up. There are several EBP studies and initiatives nationwide tackling the challenge of reducing readmissions. I suggest reading the EBP to truly understand the value of a tool to identify avoidable readmissions. A passionate nurse as yourself is what the patients need to advocate for them…. the most important person is the patient. Thank you

      ** Researchers from Yale University have identified six strategies that could help U.S. hospitals reduce 30-day Medicare readmissions by 2%—

      • Avatar
        Joseph February 2, 2016 at 10:39 pm - Reply


        Is there a way that we can access the high risk readmission form mentioned in the article? Would be really insightful to see the work you and your team did.

        Thanks in advance!

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