Download A Quality Improvement Initiative Decreases 30

A Quality Improvement Initiative Decreases 30-day Readmission Rates in Patients Admitted to a
Hepatology Service
A teaching hospital of Harvard Medical School
Elliot B. Tapper, Michelle Lai
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Problem:

The rate of readmission for patients with complicated cirrhosis is high at BIDMC and
around the country

More than 600 patients are admitted with complicated cirrhosis each year
with a baseline readmission rate of 36%

Interventions to reduce readmissions contribute to cost savings and improved patient
quality of life.

Ensuring that patients with hepatic encephalopathy receive intensive treatment
may reduce readmissions
Aim/Goal:


Standard treatment of hepatic encephalopathy (universal treatment with rifaximin
and high dose lactulose)
Standard treatment of spontaneous bacterial peritonitis

Standard prophylactic measures to prevent deep vein thrombosis and variceal
hemorrhage.

Deployed in Phases: Standards to be delivered by a checklist (at first) and later
using modifications to the electronic ordering system (electronic phase)

The 30-day readmission rate
declined and this change was
specific to our service, compared to
the BIDMC hospitalist serve and
OSH liver service
The decline in
readmissions was driven
by a reduction in
readmits for
encephalopathy
We aimed to reduce readmission rates for patients with cirrhosis and achieve
compliance with quality care standards
Description of the Intervention

Results/Findings to date:
Measurement: Analysis of outcomes, adjusting for known confounders with
statistical support (Dr. Murray Mittleman) provided by the Shapiro Center for
Education. Data provided by Gail Piatkowski (decision support). We compared our
30-day readmission statistics to the BIDMC hospitalist group and the liver service of
a regional quaternary care hospital
For a deeper look at our population’s
clinical characteristics, click here
Key Lessons Learned

The rate of readmission for patients with complicated cirrhosis is high and
modifiable

A checklist intervention with electronic decision support is a strong quality
improvement tool but electronic decision support appears superior to hand-held
checklists
Next Steps

Ensure that patients can obtain the medications prescribed as inpatients on
discharge (liaise with case management, pharmacy)

Develop an intervention to reduce the risk of renal failure

Disseminate this knowledge to other liver centers
For More Information, Contact Elliot B. Tapper; [email protected]
The Checklist
Electronic Phase
Chronic hepatic
encephalopathy Is
treated in the
usual fashion with
a PRN dose and
flag to notify an
MD if the mental
status changes
Acute hepatic
encephalopathy is
treated with
aggressive ‘goaldirected’ lactulose
To combat
underdosing of
ceftriaxone for SBP,
clinicians must chose
the indication for
ceftriaxone and then
the computer presets
a 2 gram dose
A
B
“Table 1”