A. W. Acher1,4, T. J. LeCaire1,4, A. S. Hundt2, C. C. Greenberg1,2,3,4, P. Carayon2,3, S. M. Weber1,4 4University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 1University Of Wisconsin,Wisconsin Surgical Outcomes Research Program, Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,Center For Quality & Productivity Improvement,Madison, WI, USA 3University Of Wisconsin,Department Of Industrial And Systems Engineering, College Of Engineering,Madison, WI, USA
Introduction: Prior studies on readmission neglect the patient perspective. This study sought to fill this gap by applying the Systems Engineering Initiative for Patient Safety (SEIPS) model, which places the patient at the center of the system. The objective was to identify system factors that contribute to or mitigate the risk of readmission.
Methods: Patients readmitted within 30 days of discharge (n=12) participated in a semi-structured interview with questions guided by the SEIPS framework on post-operative care, preparation for discharge, and etiology of readmission. Audio-recorded interviews were transcribed. Content analysis using a SEIPS-based coding framework was performed. Pre-specified data elements were collected concurrently from the medical record for a mixed-methods analysis.
Results: Index operations included colorectal, pancreatectomy, esophagectomy, and liver resection. Patients were readmitted a mean of 9.8 days post-discharge (SD: +/-7.3, median 8.5). Readmission diagnoses included: infection, small bowel obstruction, dehydration, pleural effusion, possible hemorrhage and palliative care. Patients identified a number of factors during transition of care from inpatient to home that may have contributed to readmission. Common findings centered on care team structure and communication, and educational process and content (Table).
Only 1/3 of patients felt they remembered all or most of their discharge instructions. Patients felt “pressured to hurry up and get it done” and a “rush to get you out of here” with insufficient time for questions. Information provided was too expansive (“so much paperwork”) with not enough “clear instruction” about specific clinical issues. Many patients (n=5) reported only being somewhat confident to prevent problems at home.
While 42% felt their care team communicated well, the remaining said “I think so” (n=4), were unsure (n=1) or disagreed (n=2). Patients (n=5) reported care team members were “not on the same page” with “every person [having] a different story about what they were going to do.” Several patients would have preferred more communication from their surgeon rather than discordant information from multiple sources.
Conclusion: This is the first study to utilize a systems engineering approach to assess the etiology of readmission from the patient perspective. Following complex surgery, readmitted patients note issues in care team structure and communication, as well as educational process and content, that may contribute to readmission. Future interventions should focus on these areas to enhance the transition of care and potentially decrease readmissions.
