Readmissions - causes and prevention

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients

These authors point out that readmission penalties have increased interest in improving care transitions. They studied 1000 general medicine patients (median age 55 years) readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013.

They found that 269 (26.9%) of the readmissions were potentially preventable.
The factors most strongly associated with potential preventability included
* emergency department (ED) decision making regarding the readmission
* failure to relay important information to outpatient health care professionals
* discharge of patients too soon
* lack of discussions about care goals among patients with serious illnesses
* inability to keep appointments after discharge
* patient lack of awareness of whom to contact after discharge

They concluded that approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

Comment: While these were 'general medicine' patients, the lessons from this study can surely be applied to the costly problem of orthopaedic  readmissions. The ED may readmit patients that can be otherwise managed, especially if there is a lack of communication with the orthopaedic service. If primary care physicians are not informed about the patient's condition, readmissions may result. Excessive emphasis on shortening the length of stay may result in discharge before the patient and family are prepared. And patients uninformed about expectations, appointments and 'who to call' may cause the patient to return to the medical center.

In that readmissions within 30 days are likely to be unfunded, it is easy to imagine the cost-savings if a quarter of the readmissions could be prevented.

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Shoulder arthritis: antibiotics after joint replacement

A common question after a shoulder joint replacement surgery regards taking antibiotics for future procedures. Obviously the goal is to minimize the risk of bacteria in the bloodstream that may result in an infection of the joint replacement.

Our usual recommendations are that (1) any elective dental (cleaning, root canals, gum surgery, etc) or other surgical procedure should be done at least six weeks before the joint replacement and the wounds should have healed completely, (2) no elective surgery be done within three months after the joint replacement and (3) prophylactic antibiotics be used for life after a shoulder joint replacement for arthritis. Of course, individual treatment plans need to be developed for individuals - these are only general guidelines based on the 2009 recommendations of the American Academy of Orthopaedic Surgeons. I recommend that you take a moment to read their information statement on antibiotics.

Often our recommendations are:

Dental work: 2 grams of cephalexin 1 hour prior to the procedure for individuals without penicillin allergy, 600mg of clindamycin 1 hour prior to the dental procedure for individuals with penicillin allergy.

The AAOS recommendations for other procedures are shown below.

Again, these are only general guidelines. The specifics for an individual patient must be established by the treating physician/surgeon.

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