TRansitions of Care
Local Site Investigator: Joshua P. Metlay, MD, PhD
Despite intense scrutiny on the need to reduce readmissions, and a proliferation of models intended to improve care transitions, surprisingly little is known about the factors which lead to readmissions, how to target interventions appropriately, or the degree to which variations in care practices (within or across sites) contribute to the likelihood of readmission. The goals of this project are 1) To collect and compare chart based measures of the adequacy of discharge coordination at The Hospital of the University of Pennsylvania and compare performance locally to that in a national network of academic medical centers, 2) To collect and compare information collected from physicians and patients about the causes of readmissions. The proposed work will be carried out at The Hospital of the University of Pennsylvania, a key member of the Hospital Medicine Reengineering Network (HOMERUN), a 15 hospital collaborative focusing on improving care of general medical patients.
The Patient Centered Transition (PaCT) Project:
Improving the Transition from Hospital to Primary Care for Socioeconomically Vulnerable Patients
Investigators: Shreya Kangovi, M.D.; Daniel Ryan, B.S.; Sharon McCollum; Mary White; Marisa Rogers, M.D.; David Grande, M.D., MPA; Richard Shannon, M.D.; Judith A. Long, M.D.
Following hospital discharge, up to 23% of patients will have an adverse medical event. The socioeconomically vulnerable are at even higher risk for poor outcomes after hospitalization. Uninsured and Medicaid patients are less likely than the privately-insured to be able to adhere to discharge medications or complete timely follow up with a primary care provider (PCP) and are 3 times more likely to return to the emergency department or be readmitted to the hospital.
Penn Medicine has partnered with Spectrum Health Services, a West Philadelphia community health center, to develop the Patient-Centered Transition (PaCT) Project. PaCT utilizes trained community health workers who provide social support, navigation and advocacy to uninsured or Medicaid patients as they transition from hospital to primary care.
PaCT, a single-blinded randomized-controlled trial, will enroll 513 patients between May 15, 2011 and May 15, 2012. Participants are uninsured or insured by Medicaid, discharged from the General Medicine services of Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC), and residents of five local ZIP codes characterized by extreme poverty where 85% of all HUP and PPMC readmitted patients reside.
The primary outcome measure of The PaCT Study is the proportion of patients who complete primary care follow-up within two weeks of hospital discharge. We will also examine the effect of PaCT on secondary outcome variables including patients’ satisfaction with the experience of transition, medication adherence, self-rated health, and ED revisit or inpatient readmission within 30 days after discharge.
Describing Communication Between Inpatient and Outpatient Dialysis Providers at Hospital Discharge
Investigator: James Reilly, MD
Patient handoffs have increased due to the complexity of healthcare, the hospitalist movement, and resident duty hour restrictions. Regulatory bodies have recognized the safety hazards associated with poor handoffs and have called for additional training and standardization of the process.
A growing body of literature describes best practices in general hospital discharges, but little is known about the challenges and opportunities in discharge communication between inpatient and outpatient dialysis providers. Studies are needed to describe and evaluate the process of handing off dialysis-specific information between inpatient and outpatient dialysis units in hopes of decreasing morbidity, mortality, and unnecessary health care costs in this vulnerable and complex population.
To address this gap in knowledge, we performed semi-structured interviews with thirty to forty providers (physicians, nurse practitioners, nurses or dialysis social workers) from a sample of the inpatient dialysis units at the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Penn-affiliated Davita Dialysis Units, and selected non-Penn Davita outpatient dialysis units in West Philadelphia whose patients are frequently admitted to Penn hospitals. After standards of high-quality communication are defined, they will be used to evaluate current performance and guide development of an intervention to realize a consistent, reliable process of high-quality communication between dialysis units at discharge. Description of previous adverse events will inform anticipation and prevention of such future potential events. Top ↑
Improving CPR Quality and Resusitation Training by Combining Audiovisual Feedback and Debriefing
Investigator: Benjamin Abella, MD, MPhil
In-hospital cardiac arrest (IHCA) is a widespread problem for hospital healthcare providers and carries a high mortality rate. IHCA events often occur with little warning and require a time-sensitive coordinated team approach to care. While most providers are trained in the basic skills of resuscitation, such as CPR and Advanced Cardiac Life Support (ACLS), very little effort across the hospital environment is placed on team training or improving the quality of care during IHCA events. A growing body of evidence suggests that IHCA outcomes are highly dependant on resuscitation performance variables such as CPR quality, pauses in CPR delivery, and time to defibrillation. Our preliminary work has suggested that periodic resuscitation team debriefing may serve as a useful method to improve subsequent care quality and initial patient survival outcomes.
To extend this work, we will prospectively study the use of immediate team debriefing on subsequent care quality during cardiac arrest events in the critical care setting. Defibrillators in the medical intensive care unit and cardiac care unit have been outfitted with sensors to detect and record chest compression rate and depth, CPR pause times, and other objective metrics of resuscitation performance. These data will be the core material for focused debriefings immediately following IHCA events, and longitudinal data on CPR quality and outcomes will be collected as well.