When we consider making changes to current clinical practice and follow-up with a goal of preventing hospital readmissions, we are using data that may not give us a clear picture of the challenges across populations. Some recent studies have looked at the differences in early and late readmission--those readmissions within eight days of discharge, compared to within thirty days of discharge; other studies are looking at the origin of the patient at readmission--home, long-term care facilities, or skilled nursing facilities. Further studies are looking at variables such as insurance status of patients who are readmitted, comparing Medicare, Medicaid, and uninsured people on admitting diagnosis.
All of these studies suggest the problem is more complex, and the solutions will need to be more complex, than we realized. But two areas of concern have been identified, and need to be addressed.
Medicare is tracking readmission rates by diagnosis. Admitting diagnoses of congestive heart failure, acute MI, pneumonia, COPD exacerbations were followed by different readmissions diagnoses. Up to 68% of readmissions occurred in the first 15 days after discharge, and the most common readmission diagnosis across all diagnostic categories was sepsis.
Medicare is also tracking where people are being readmitted from--home or long term care? Patients who originally came from long-term care facilities and skilled nursing facilities are more likely to be readmitted; the most common diagnosis, sepsis.
Some of this is understood to be related to the overall degree of illness and debility the patient suffers. If cognitive decline or stroke impacts the ability to communicate, then people end up sicker before we can intervene. They are not able to describe the way they are feeling, and only when physical symptoms appear can care providers begin looking for the problem and finding treatments. Sepsis in the frail elderly can be insidious, and many times does not present with fever or other typical markers, but a vague confusion, restlessness, or agitation. So this difficulty with communication and assessing signs of developing infections and sepsis complicates the picture for those in long term care facilities.
Another issue impacting readmission rates is the increase in errors when people are transitioning from one setting to the other. Discharge planning, which often focuses on home-bound elders, also needs to ensure excellent communication with those in institutional care. Medication reconciliation, pulmonary hygiene, and careful monitoring for sepsis is critical.
Hospital stays are well known for causing colonization with c. difficile and multi-drug resistant bacteria. When a previously hospitalized person goes back to a long term care facility with both a weakened immune system from the original diagnosis and the stress of hospitalization, and the colonization with dangerous pathogens that occurs in hospitals, the risk of sepsis, and spreading resistant nosocomial infections is high. It is critical for those who are returning to a long term care facility after hospitalization to ensure very good handwashing, room cleaning, and monitoring for signs of drug resistant colonization and infections, especially in the person who experienced significant instrumentation during hospitalization.
Those who had urinary catheters while in the hospital should be monitored for bacteriuria; multiple IVs or other invasive blood vessel instrumentation need monitoring for bacteremia. Careful isolation for a previously hospitalized patient with new onset diarrhea should include rapid assessment for c. difficile.
Many times discharge planners feel more comfortable sending people back to a skilled nursing facility or long term care facility after hospitalization, with the idea patients will be able to resume their routines and someone will be monitoring them. But the high rates of sepsis readmissions suggest we look with more depth at how well people are able to communicate. We need careful and detailed monitoring for signs of infection and sepsis when instrumentation was present, careful isolation to prevent the spread of c. difficile in an institutional population, and environmental efforts to stop the spread of multi-drug resistant germs on those returning after hospitalization.
For more information on avoiding hospital readmission, please contact us.