Background: Readmissions are costly to the healthcare system have been associated with low patient satisfaction scores, longer length of stay, and higher mortality. Identifying and addressing patient needs at the time of transitioning care from the inpatient to outpatient setting has the potential to reduce readmission rates. The purpose of our project was to develop and evaluate a multi-disciplinary discharge process in a phased fashion for high-risk patients that was highly utilized and led to a decrease in readmissions at a tertiary care center

Methods: We used a previously validated, internally developed scoring system called Hospital Admission Readmission Risk Discriminator (HARRD) score to identify patients at high risk of readmissions. A HARDD score of 4 or 5 correlated with a readmission risk score of 36% (table 1). We convened a bedside huddle within 24-48 hours of discharge for patients with HARDD score of 4 or 5. The multidisciplinary bedside huddle team consisted of the patient’s primary inpatient provider (attending, advanced practice provider or resident physician), bedside and charge nurse, pharmacist, case manager, and physical or occupational therapist. Charge nurses were tasked with leading the huddle. The process started with a standardized questionnaire assessing the patient and family’s concerns about the discharge process. Such concerns were addressed on a priority basis, followed by education on expected disease course, expected symptoms and management, medication management, hospital follow up and the role of family and caregivers. We have 3 General Internal Medicine (GIM) units at our 550-bed facility. Huddles were piloted on 1 unit during the first two months of the project (phase 1), expanded to 2 units over the next 5 months (phase 2), and finally implemented on all 3 units at the end of 7 months (phase 3). Based on feedback from team members and data analysis from each cycle, we made several changes from phase 1 to phase 3. These included adding additional qualifying criteria for huddles, excluding specialty patient populations who already had excellent post discharge follow up (such as sickle cell patients), modifying the standardized questionnaire used during huddles, and developing a script to run huddles so any team member could conduct a huddle when the charge nurse was unavailable. The current huddle process is shown in figure 1.

Results: A total of 34 huddles were conducted over two months during phase 1 of the project. The 30-day readmission rate of huddled patients was 20% as compared to the historical 36% readmission rate for patients with a HAARD score of 4 or 5 at our institution. Over the 5-month second phase, a total of 43 huddles were performed on two medicine units. The overall 30-day readmission rate was lower among high-risk patients who received a bedside huddle versus eligible high-risk patients who did not receive a huddle (20.9% versus 41%, p=0.023). A total of 79% (287/361) of eligible patients received a huddle after the process was expanded to all 3 GIM units (phase 3). The 30-day readmission rate in high-risk patients who received a huddle was 26.13% (75/287) versus 33.78% (25/74) among high-risk patients who did not receive a huddle (p=0.18).

Conclusions: Our results show that an iterative deployment of a project intended to reduce readmissions through the use of a multidisciplinary bedside huddle prior to discharge for high-risk patients can lead to an intervention not only with very high uptake but also resulting in sustainable reductions in readmissions for high-risk patients.

IMAGE 1: HAARD score

IMAGE 2: Figure 1: Huddle process