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Low Hospital Readmission Rates Achieved at Rural Bariatric Center Through Education and A Standardized Discharge Protocol
S102
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Introduction: A rural mid-volume center of excellence (COE) community hospital in northern California, Enloe Medical Center, maintains below average readmission rates, even exceeding the rates recently published by Stanford (who recently reduced their readmission rates from 8% to 2.5% over 18 months). The program has maintained the standards and status of COE since 2006, and has reduced 30-day readmissions post bariatric surgery from 3.4 % from 2006-2011 (16:864) to 1.3% from 2012 to 2014 (8:616). Methods: As our volume of primary bariatric surgeries has increased from 130 in 2006 to 250 patients in 2014, the Vertical Sleeve Gastrectomy (VSG) became the dominant surgery performed, while the Roux-en-y (RNY) and Adjustable Gastric Band (AGB) decreased significantly. All surgeries were done laparoscopically. The average length of stay (LOS) for all procedures from 2012-2014 decreased to 1.4 days (compared to 2.5 days from 2006-2011). The hospital is a 298-bed non-profit rural community
Conclusion: The completed data did not exhibit a statistical significance in the first arm of study using videotelecommunication with nutritional and psychotherapeutic sessions as compared to the face to face sessions with weight loss post LSG. In the second arm of the study, there was a comparison of the compliance with follow-up participation in the face to face group (90%) to the video-telecommunication group as seen in the (30%) recidivism rate. A5089
LOW HOSPITAL READMISSION RATES ACHIEVED AT RURAL BARIATRIC CENTER THROUGH EDUCATION AND A STANDARDIZED DISCHARGE PROTOCOL Joyce Todd, RN; Deron Ludwig, MD; Erik Simchuk, MD; Anna Coates, NP; Chico, CA, USA
700
3.5%
600
3.0%
500
2.5%
400
2.0%
300
1.5%
200
1.0%
100
0.5%
Readmission Percentage
Total Surgeries
Bariatric Surgeries by b Type an nd Total Re eadmission n Rates
Gastric Slee eve Roux-EN-Y Gastric Band Readmisson n Rate
0.0%
0 2012-2014
2006-2011
Calendar Year Ye Range Notes N A All case and readmission data wass provided by Joyy Todd, Coordinattor of Enloe’s Barriatric Program.
6.0%
250
5.0%
200
4.0%
150
3.0%
100
2.0%
50
1.0%
0
0.0% 2 2006
2007
2008
2009
0 2010
2011
2012
20113
Calendarr Year N Notes All case and readmission data wass provided by Joyy Todd, Coordinattor of Enloe’s Barriatric Program. A
2014
Readmission Percentage
Total Surgeries
Surge eries by Tyype and Tottal Readmission Ratees 300
Gastric Sleeve Roux-EN-Y Gastric Band Readmisson Ra ate
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
hospital. Data is collected by chart review and review of a prospectively maintained database. Our program has two bariatric surgeons who assist each other with most surgeries and alternate call. Robust patient educational programs include five points of contact by a bariatric nurse (education at initial seminar, pre-op bariatric class, pre-op testing appointment, in-patient educational hospital visit, and follow up phone call). Surgeons are available to patients (by phone call and appointment) and mentors are assigned to patients who desire additional support. Hospital discharge educational process includes written and verbal education from the bariatric nurse coordinator, primary care nurse, and in-patient dietitian on the day of discharge; family members are encouraged to be present for all education. All patients are called 1-3 days after discharge (prior to the weekend) from the hospital to ensure understanding and compliance with instructions and to troubleshoot any problems. All patients are seen by the surgeon the week following operation prior to advancing beyond a liquid diet. Results: Readmission rates have remained below national average since the program emerged as a COE in 2006 and have decreased significantly in the past three years. National average readmission rates are currently 4.95% for all procedures. Program readmission rates decreased to an average of 1.3% for the past 3 years (down from 3.4% in years 2006-2011). High risk patients are included as follows: for the years 2012-2014: Patients with BMI 450: 20.9% (N¼129), BMI460 4.2% (N¼26), BMI470: 0.5% (N¼3); conversions from AGB to VSG 2.5% (N¼15); and older patients: 21.2% 460 years old, 1.2% 470 years old. Decreasing an already low readmission rate was felt to be accomplished by replacing the RNY with the VSG as the primary surgery and increasing volume of bariatric surgeries, while maintaining a robust education and discharge process protocol Conclusion: Increased safety in bariatric surgery, demonstrated by decreased re-admissions and shorter LOS, can be achieved even at a rural mid-level volume hospital when Center of Excellence standards are followed, robust educational programs are utilized, and a standardized discharge education protocol is implemented and maintained. Utilizing the VSG as the primary surgery appears to further reduce readmission rates and shorten LOS while maintaining results comparable to the RNY.
A5090
PREDICTING PREVENTABLE CAUSES AFTER BARIATRIC SURGERY: A LOOK INSIDE THE “BLACK BOX” Shannon Brindle, MD; Piotr Krecioch, MD; Thomas Shin, MD; Marie Hunsinger, RN; James Dove, BA; William Strodel, MD; Jon Gabrielsen, MD; Anthony Petrick, MD; Gesinger Medical Center, Danville, PA, USA Background: Readmission rates are increasingly used as a surrogate for quality in medicine. Surgical readmissions are associated with poorer overall clinical outcomes as well as significant financial risks for patients as well as providers. Understanding readmissions is challenging because the definition of a readmission varies nationally, regionally and even locally. Different payers have different criteria for defining readmissions. Given this difficulty, understanding what may be preventable
S103
Causes of Preventable versus Non-preventable Readmissions Indication for Readmission Obstrucon NVD Wound Stricture Resp Renal Cardiac Bleed Leak
Non-preventable
Preventable
p-value
14 (23.3%) 20 (33.3%) 7 (11.7%) 3 (5%) 7 (11.7%) 3 (5%) 5 (9.8%) 16 (26.7%) 15 (25%)
5 (9.4%) 33 (62.3%) 4 (7.6%) 1 (1.9%) 3 (5.7%) 1 (1.9%) 0 (0%) 7 (13.2%) 0 (0%)
0.049 0.002 0.461 0.621 0.262 0.621 0.063 0.076 <.0001
readmissions becomes even more difficult. Recent studies suggest that many bariatric readmissions may be preventable. A study from New York State used proprietary software to calculate the prevalence of preventable readmissions; however, due to the complexity of the software, the specific definition of a preventable readmission was not outlined in the report. The objective of this study was to define readmissions after bariatric surgery and then to determine the incidence of preventable readmissions as well as identify modifiable factors that might assist in decreasing readmission rates. Methods: This is a retrospective review of all readmitted bariatric patients after an initial Roux-en-Y gastric bypass (RYGB) or Sleeve Gastrectomy (LSG) from May 1, 2007 through April 30, 2014. Any patient readmitted to the hospital for any length of stay within 30 days of discharge was defined as a readmission. All admissions to outside facilities within 30 days of surgery were included. An emergency room visit was not considered a readmission and no patient remained in the emergency room for more than 23 hours. Readmissions were first classified as unrelated or related to the initial surgery. A readmission was classified as unrelated if the indication (admission diagnosis) was not associated with a surgical diagnosis or a complication and the patient did not receive direct treatment during the initial stay. Patients were also classified as no readmission (NR), preventable readmission (PR) or non-preventable readmission (NPR). A readmission was considered preventable if improvements in a health care process (i.e. discharge, follow up or outpatient management) could have prevented the readmission. Preoperative demographic factors and comorbidities as well as perioperative factors were analyzed using both univariate and multivariate analysis. Patients with preventable readmissions were compared to those with no readmission and also to those with non-preventable readmissions. Results: A total of 2113 patients underwent either RYGB or LSG during the study period. 96% of patients and all readmitted patients were available for 30 days post-operative analysis. There were no significant differences in age, BMI, or sex for any of the three groups. One hundred and thirteen patients (55%) were readmitted during the study period and 25 were for less than 2 midnights (22%). 84% of readmission for less than 2 midnights were considered PR. Of the total readmitted 60 (53%) were NPR and 53 (47%) were PR. Of the PR 49 (92.5%, p¼0.058) were related to the initial surgery. Patients with a readmission indication of nausea, vomiting or dehydration (NVD) were the most likely to have a PR (62.3% v 33.3%, p¼0.002). [Table #1] NPR were more likely for those admitted with a major complications (53.3% v 15.1%, p o0.0001), including obstructions and leaks as well as those requiring reoperation (38.3% v 13.2%, p¼0.003). Compared to NPR, the time to readmission was one shorter for the PR (6 vs.
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Introduction: A rural mid-volume center of excellence (COE) community hospital in northern California, Enloe Medical Center, maintains below average readmission rates, even exceeding the rates recently published by Stanford (who recently reduced their readmission rates from 8% to 2.5% over 18 months). The program has maintained the standards and status of COE since 2006, and has reduced 30-day readmissions post bariatric surgery from 3.4 % from 2006-2011 (16:864) to 1.3% from 2012 to 2014 (8:616). Methods: As our volume of primary bariatric surgeries has increased from 130 in 2006 to 250 patients in 2014, the Vertical Sleeve Gastrectomy (VSG) became the dominant surgery performed, while the Roux-en-y (RNY) and Adjustable Gastric Band (AGB) decreased significantly. All surgeries were done laparoscopically. The average length of stay (LOS) for all procedures from 2012-2014 decreased to 1.4 days (compared to 2.5 days from 2006-2011). The hospital is a 298-bed non-profit rural community
Conclusion: The completed data did not exhibit a statistical significance in the first arm of study using videotelecommunication with nutritional and psychotherapeutic sessions as compared to the face to face sessions with weight loss post LSG. In the second arm of the study, there was a comparison of the compliance with follow-up participation in the face to face group (90%) to the video-telecommunication group as seen in the (30%) recidivism rate. A5089
LOW HOSPITAL READMISSION RATES ACHIEVED AT RURAL BARIATRIC CENTER THROUGH EDUCATION AND A STANDARDIZED DISCHARGE PROTOCOL Joyce Todd, RN; Deron Ludwig, MD; Erik Simchuk, MD; Anna Coates, NP; Chico, CA, USA
700
3.5%
600
3.0%
500
2.5%
400
2.0%
300
1.5%
200
1.0%
100
0.5%
Readmission Percentage
Total Surgeries
Bariatric Surgeries by b Type an nd Total Re eadmission n Rates
Gastric Slee eve Roux-EN-Y Gastric Band Readmisson n Rate
0.0%
0 2012-2014
2006-2011
Calendar Year Ye Range Notes N A All case and readmission data wass provided by Joyy Todd, Coordinattor of Enloe’s Barriatric Program.
6.0%
250
5.0%
200
4.0%
150
3.0%
100
2.0%
50
1.0%
0
0.0% 2 2006
2007
2008
2009
0 2010
2011
2012
20113
Calendarr Year N Notes All case and readmission data wass provided by Joyy Todd, Coordinattor of Enloe’s Barriatric Program. A
2014
Readmission Percentage
Total Surgeries
Surge eries by Tyype and Tottal Readmission Ratees 300
Gastric Sleeve Roux-EN-Y Gastric Band Readmisson Ra ate
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
hospital. Data is collected by chart review and review of a prospectively maintained database. Our program has two bariatric surgeons who assist each other with most surgeries and alternate call. Robust patient educational programs include five points of contact by a bariatric nurse (education at initial seminar, pre-op bariatric class, pre-op testing appointment, in-patient educational hospital visit, and follow up phone call). Surgeons are available to patients (by phone call and appointment) and mentors are assigned to patients who desire additional support. Hospital discharge educational process includes written and verbal education from the bariatric nurse coordinator, primary care nurse, and in-patient dietitian on the day of discharge; family members are encouraged to be present for all education. All patients are called 1-3 days after discharge (prior to the weekend) from the hospital to ensure understanding and compliance with instructions and to troubleshoot any problems. All patients are seen by the surgeon the week following operation prior to advancing beyond a liquid diet. Results: Readmission rates have remained below national average since the program emerged as a COE in 2006 and have decreased significantly in the past three years. National average readmission rates are currently 4.95% for all procedures. Program readmission rates decreased to an average of 1.3% for the past 3 years (down from 3.4% in years 2006-2011). High risk patients are included as follows: for the years 2012-2014: Patients with BMI 450: 20.9% (N¼129), BMI460 4.2% (N¼26), BMI470: 0.5% (N¼3); conversions from AGB to VSG 2.5% (N¼15); and older patients: 21.2% 460 years old, 1.2% 470 years old. Decreasing an already low readmission rate was felt to be accomplished by replacing the RNY with the VSG as the primary surgery and increasing volume of bariatric surgeries, while maintaining a robust education and discharge process protocol Conclusion: Increased safety in bariatric surgery, demonstrated by decreased re-admissions and shorter LOS, can be achieved even at a rural mid-level volume hospital when Center of Excellence standards are followed, robust educational programs are utilized, and a standardized discharge education protocol is implemented and maintained. Utilizing the VSG as the primary surgery appears to further reduce readmission rates and shorten LOS while maintaining results comparable to the RNY.
A5090
PREDICTING PREVENTABLE CAUSES AFTER BARIATRIC SURGERY: A LOOK INSIDE THE “BLACK BOX” Shannon Brindle, MD; Piotr Krecioch, MD; Thomas Shin, MD; Marie Hunsinger, RN; James Dove, BA; William Strodel, MD; Jon Gabrielsen, MD; Anthony Petrick, MD; Gesinger Medical Center, Danville, PA, USA Background: Readmission rates are increasingly used as a surrogate for quality in medicine. Surgical readmissions are associated with poorer overall clinical outcomes as well as significant financial risks for patients as well as providers. Understanding readmissions is challenging because the definition of a readmission varies nationally, regionally and even locally. Different payers have different criteria for defining readmissions. Given this difficulty, understanding what may be preventable
S103
Causes of Preventable versus Non-preventable Readmissions Indication for Readmission Obstrucon NVD Wound Stricture Resp Renal Cardiac Bleed Leak
Non-preventable
Preventable
p-value
14 (23.3%) 20 (33.3%) 7 (11.7%) 3 (5%) 7 (11.7%) 3 (5%) 5 (9.8%) 16 (26.7%) 15 (25%)
5 (9.4%) 33 (62.3%) 4 (7.6%) 1 (1.9%) 3 (5.7%) 1 (1.9%) 0 (0%) 7 (13.2%) 0 (0%)
0.049 0.002 0.461 0.621 0.262 0.621 0.063 0.076 <.0001
readmissions becomes even more difficult. Recent studies suggest that many bariatric readmissions may be preventable. A study from New York State used proprietary software to calculate the prevalence of preventable readmissions; however, due to the complexity of the software, the specific definition of a preventable readmission was not outlined in the report. The objective of this study was to define readmissions after bariatric surgery and then to determine the incidence of preventable readmissions as well as identify modifiable factors that might assist in decreasing readmission rates. Methods: This is a retrospective review of all readmitted bariatric patients after an initial Roux-en-Y gastric bypass (RYGB) or Sleeve Gastrectomy (LSG) from May 1, 2007 through April 30, 2014. Any patient readmitted to the hospital for any length of stay within 30 days of discharge was defined as a readmission. All admissions to outside facilities within 30 days of surgery were included. An emergency room visit was not considered a readmission and no patient remained in the emergency room for more than 23 hours. Readmissions were first classified as unrelated or related to the initial surgery. A readmission was classified as unrelated if the indication (admission diagnosis) was not associated with a surgical diagnosis or a complication and the patient did not receive direct treatment during the initial stay. Patients were also classified as no readmission (NR), preventable readmission (PR) or non-preventable readmission (NPR). A readmission was considered preventable if improvements in a health care process (i.e. discharge, follow up or outpatient management) could have prevented the readmission. Preoperative demographic factors and comorbidities as well as perioperative factors were analyzed using both univariate and multivariate analysis. Patients with preventable readmissions were compared to those with no readmission and also to those with non-preventable readmissions. Results: A total of 2113 patients underwent either RYGB or LSG during the study period. 96% of patients and all readmitted patients were available for 30 days post-operative analysis. There were no significant differences in age, BMI, or sex for any of the three groups. One hundred and thirteen patients (55%) were readmitted during the study period and 25 were for less than 2 midnights (22%). 84% of readmission for less than 2 midnights were considered PR. Of the total readmitted 60 (53%) were NPR and 53 (47%) were PR. Of the PR 49 (92.5%, p¼0.058) were related to the initial surgery. Patients with a readmission indication of nausea, vomiting or dehydration (NVD) were the most likely to have a PR (62.3% v 33.3%, p¼0.002). [Table #1] NPR were more likely for those admitted with a major complications (53.3% v 15.1%, p o0.0001), including obstructions and leaks as well as those requiring reoperation (38.3% v 13.2%, p¼0.003). Compared to NPR, the time to readmission was one shorter for the PR (6 vs.