AT THE ACS QUALITY & SAFETY CONFERENCE
NEW YORK (FRONTLINE MEDICAL NEWS) – Targeted interventions aimed at reducing patient readmission after bariatric surgery at a high-volume academic medical center led to a 61% overall decrease year over year. The center also saw a substantial reduction in readmissions linked to the top three factors of readmission identified by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, as well as a precipitous drop in the revisional surgery readmission rate.
“Our center, like so many others, has quarterly meetings in accordance with the MBSAQIP to look at our data. And this led to recognition of some common reasons for readmission,” said Chetan V. Aher, MD, a general surgeon at the department of surgery at Vanderbilt University Medical Center in Nashville, Tenn. Oral (PO) intolerance, dehydration, and nonemergent abdominal pain were the top reasons flagged by the MBSAQIP registry data at the medical center. Dr. Aher and his colleagues moved to focus on postoperative diet, administration of medications, management of patients who return to the hospital after surgery, and optimal staffing.
After comparing MSBAQIP data for 471 bariatric operations in 2015 with data from 539 surgeries in 2016, “we saw a pretty significant reduction in our readmission rates. Overall we had a decrease of 61%, from 6.6% to 2.6%.” There was also a 45% decrease in readmission rates related to the top three reasons – PO intolerance, dehydration, and nonemergent abdominal pain – combined.
“Notably, the readmission rate for revisional procedures decreased by a whopping 90%,” Dr. Aher said. “I think a lot of these targeted interventions just really helped these patients who were at a higher risk to begin with to be readmitted.”
New dietary dos and don’ts
“We changed our postoperative diet,” Dr. Aher said. Instead of a soft food diet a couple of days after surgery, the full liquid diet was extended to 3 weeks post surgery.
The clinicians also implemented what they called a ‘no MEALS’ policy, which stands for no Meat, Eggs And Leftovers. “We were having problems with meat, although tender fish was okay, and some other things that went down easily,” Dr. Aher said at the American College of Surgeons Quality and Safety Conference. “We had some complaints about no eggs after surgery. A lot of patients love eggs,” he added. But they recommended avoiding eggs for 1 month after bariatric surgery to avoid nausea.
“Avoiding leftovers was also a big deal for patients,” Dr. Aher said. But patients who microwaved leftovers would “then come into the hospital with problems.”
Medication modifications
Another frequent cause of nausea was a “terrible and off-putting” taste when crushed tablets or medication capsules were added to the patient’s diet. Changing how patients took their medication “was a big help.” At the same time, there was a large institutional effort at Vanderbilt to start providing discharge medications in the hospital to increase postoperative compliance. “Bariatric surgery was one of the pilot programs for this,” Dr. Aher said. Discharge medications were filled by the pharmacy at Vanderbilt and delivered to the patient’s room, and a pharmacist or pharmacy intern explained how to use them. Compliance on medications increased, which may in turn have had an impact on readmissions.
Changes to patient management
Dr. Aher and his colleagues also changed where they treated patients who returned with problems. “Previously, when patients called in, the clinic diverted them to the emergency room. We stopped doing that, and increased our capacity to see these patients in the clinic instead.” This led to an increase in use of IV hydration in the clinic.
A meeting attendee asked if providing this service led to any problems with clinic capacity.
“Sometimes,” Dr. Aher said. “We don’t have a huge number of patients coming in for IV hydration, but when we had two come in on the same day, it did take up a couple of exam rooms.” To address this, the clinicians found other space in the clinic that would offer privacy for patients while not tying up exam rooms.
In addition, the clinic expanded nurse practitioner availability to 5 days a week to make the discharge process more consistent. “Of course, as we rolled all these things out, we made sure our educational material was updated accordingly,” Dr. Aher said.
The study demonstrates that a collaborative team effort and targeted interventions can result in a significant reduction in readmissions, Dr. Aher said. “Regular quality focused meetings are really important to facilitate recognition of various areas for improvement, especially in a high-volume center. Introducing an MBSAQIP registry serves as an excellent tool to effect these changes,” he said.
Dr. Aher had no relevant financial disclosures.
