Background:
The Institute for Healthcare Improvement recommends that unplanned readmissions within 30 days of discharge prompt a formal case review to identify systematic flaws in discharge processes. As frontline providers, residents may have insights that can help assess readmission preventability and identify underlying system flaws that lead to readmissions. We therefore developed a readmission case review system with medical interns on a quality improvement (QI) rotation in order to understand the epidemiology and pre‐ventability of our unplanned readmissions.
Methods:
Beginning in June 2010, all unplanned readmissions within 30 days of discharge were reviewed in real time by interns during a 2‐week QI rotation. Interns used a standardized form to analyze cases via chart review, discussions with the discharging and readmitting physicians, and patient interviews. Interns were asked to describe the reasons for readmission including preventable factors related to the discharge process (see Table 1). Patients could have multiple reasons for readmission. Three attending hospitalists independently reviewed 30 cases that had been completed by the interns.
Results:
Interns reviewed 111 consecutive cases. Reason for readmission was often multi‐factorial: 10% of patients had 3 and 36% had 2 identifiable factors that contributed to their readmission. Interns considered most readmissions to be nonpreventable (see Table 1). However, 35% of patients had a preventable reason for readmission (see Table 2), with medication‐related events being most frequent. Thirty percent of patients had both preventable and nonpreventable reasons for readmission, for example, worsening of underlying disease and inadequate family support. The attending faculty agreed with the intern assessments of preventability 80% of the time; when they disagreed, they thought an additional preventable factor contributed to the readmission. Interns had difficulty identifying broader, systems‐based problems. For example, they attributed uncontrolled pain in a metastatic cancer patient to worsening of underlying disease, whereas attendings thought the admission could have been prevented if palliative care was consulted on the index admission. Also, nearly half the “new diagnoses” at readmission were hospital‐acquired infections, which are often preventable.
TABLE 1 Nonpreventable Reasons for Readmission
TABLE 2 Preventable Reasons for Readmission
Conclusions:
Our case series highlights that reasons for readmission are often multifactorial, and a significant proportion of patients have both preventable and nonpreventable reasons for readmission. We also found that compared with faculty assessment, interns underestimate the preventability of readmissions.
Disclosures:
S. Iobst ‐ none; S. Ranji ‐ none