28-276 / Testing interventions to reduce urology patient readmissions

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
University College London NHS Hospitals Foundation Trust


Quality improvement project
Patient empowerment

GOP Description
Implementation level
Clinical settings
The clinical setting was a urology surgery ward. Ward staff and specialist nurses were involved in testing interventions from the State-wide Action to Reduce Re-hospitalizations (STAAR) initiative to reduce readmissions.
Patient non-compliance with taking their medications causes preventable readmissions which lead to poor patient experience and increased length of stay. The objectives of the GOP were to develop, PDSA test and implement quality improvement interventions to reduce Urology patient readmission rates using a 90 day rapid improvement cycle approach.
Urology surgery patients
Baseline data on 30 day urology readmission rates was collected. This showed that the rate of urology surgery admissions was over twice the Trust average (i.e. 15% compared to a Trust average of ~6%). Patient interviews and case note review of urology surgery readmissions were carried out. Length of stay and cost of readmissions were calculated. This showed that the average length of stay for a readmitted urology surgery patient was 2 days. It was estimated that over 9 months there had been a loss of income of around L174,000 from the urology surgery readmissions.

Case note review identified sixty-five preventable readmissions from April 1st 2011 to January 31st 2012. Figure 1 shows that the majority of patients were readmitted out of hours.

To reduce readmission rates amongst urology surgery patients, the following prototypes were developed and PDSA tested:

•    Patient information traffic light sheets for cystoscopy, bladder reconstruction and tine line neuromodulation patients.
•    A single point of access telephone number which patients could call to discuss post-discharge concerns or issues.
•    A teach back medication protocol combined with a post-discharge survey, medication reminder chart and 48 hour teach back follow up to check patient understanding of their medications post-discharge.

Timeframe implementation
The work was carried out using a 90 day rapid improvement cycle approach. Further work has been carried out since the completion of the 90 day rapid improvement cycle to spread the quality improvement interventions across the ward.
Implementation tools available
Copies of the prototype patient information traffic light sheets and the teach back protocol are available on request.
Implementation cost
The cost of backfilling the Charge Nurse who led the work for 2 days per week was around L9,000.00
Method used to measure the results
Urology patient readmission rate data was collated (Figure 2). ‘Tracking data’ on patients involved in PDSA testing was also collected to identify whether each patient had been readmitted within 30 days of discharge. Results showed that three out of twenty-nine patients were readmitted (10%).
PDSA feedback showed:
•    Patient information traffic light sheets make post discharge information and guidance simple. Patient feedback was unanimously positive. Patients reported that they had never had post-discharge information presented to them in such a simple and accessible format before
•    A single point of access telephone number ensures patients have access to urology expertise ‘out of hours.’ A log book of calls made to ward staff using the single point of access telephone number has proven that the system not only prevents readmissions but also acts as an early warning system to identify patients suffering serious complications.
Analysis of the results
Using teach back for medications pre-discharge and 48 hours post discharge gives staff confidence that patients and carers have understood their medications.

The interventions have improved both patient experience and post-discharge understanding of medications.

Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Our plan to engage community care partners in the improvement was not achieved. Originally, we planned to engage community nurses in using teach back to check patient and carer understanding of their medications after the patient had been discharged from hospital.
Describe the strategies used to overcome the barriers (If needed)
However, we were unable to translate the links we made with community care providers into discernible action. Future work on teach back would benefit from harnessing the engagement of community care providers.
Other information
Other information about the GOP that you would like to add (Link or attached document)
Copies of the traffic light patient information sheet for cystoscopy patients and the teach back medication protocol available on request.

Further information on the work we have carried out in this area is available by contacting Dr Jane Carthey at [email protected]