Elena Ruocco
Houston Methodist Hospital, USA
Title: 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 disease (COPD)
Biography
Biography: Elena Ruocco
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 through 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 pharmocologic 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.