Nurses Help Reduce Hepatology Patient Readmission Rates

In January 2016, the 30-day readmission rate among patients discharged from the inpatient medicine unit at Cleveland Clinic’s main campus that cares for patients with digestive diseases, such as hepatic encephalopathy and kidney injury, was 54.2 percent. While the acuity level of patients on the unit is high, staff set a goal to decrease 30-day readmission rates. A multidisciplinary team from Cleveland Clinic’s Digestive Disease & Surgery Institute – including nurses, physicians, internal medicine residents, pharmacy and case managers – worked together to achieve the goal as part of a quality improvement project.

“As we examined readmissions, we couldn’t really nail down one specific reason why our 30-day readmission rates were higher than we would like,” says Donna Oliver, MSN, MBA, RN, former Nurse Manager of the unit. “But as we boiled things down, one of the things we thought we were missing was post-discharge follow-up for these patients.”

Patient education is key

The team devised several interventions to reduce 30-day readmission rates, including the development of a specialty care coordinator role filled by an RN, a hepatic encephalopathy (HE) discharge education class, and shared medical appointments for recently discharged patients.

Annie Sobotka, RN, was hired in February 2016 to serve as specialty care coordinator, working with patients before and after discharge to ensure that they receive continuity of care. Her responsibilities include patient assessment, development of patient-specific plans of care and education, development of patient education material, coordination with the inpatient team for patients’ transition to ambulatory care, and support to patients and caregivers while at home.

Sobotka also co-leads weekly HE discharge education classes, along with Shannon Rives, MSN, RN, ACNS-BC, CCRN, CMSRN, a clinical nurse specialist for the inpatient hepatology service. The topics and materials were created with input from Carlos Romero-Marrero, MD, from the Department of Gastroenterology & Hepatology. “It’s a one-hour class held every Wednesday at 1 p.m. where patients and their caregivers come together in a group setting,” says Rives. They cover three main topics:

1. Precipitating factors – The nurses discuss factors that can contribute to HE, including constipation, dehydration, fluid buildup, use of alcohol and certain drugs, poorly controlled diabetes and infection or bleeding related to liver disease.
2. Medications – The class covers the importance of medication related to HE, such as lactulose, rifaximin and zinc.
3. Nutrition – Sobotka and Rives talk about the importance of eating protein, maintaining a low-sodium diet, planning meals, and eating three meals and three snacks daily.

If patients and their caregivers are unable to make the class, nurses on the unit provide this education.

“We try to keep the class as fluid as possible. We’ve added in a piece that tells people when to call [the specialty care coordinator],” says Rives. “We tell people that sometimes HE is part of having liver disease even though they are doing all the right things. So knowing the early signs – and when to get medical help – is really important.”

In January 2017, the inpatient hepatology service began offering shared medical appointments with recently discharged patients, and in March 2017 the unit began interdisciplinary rounds with nurses, physicians and a pharmacy technician to ensure that patients have and understand any newly prescribed medications.

Intervention leads to positive outcomes

This multifaceted education process is working for patients. Sobotka shared the story of a patient who was admitted for kidney injury and HE. Once discharged, the patient attended the HE education class and the follow-up shared medical appointments. “She used the tools she learned in the class and at the shared appointments. She learned how to safely take lactulose without getting dehydrated and how to identify if she was becoming confused. She was vigilant about getting lab work done,” says Sobotka. “The patient was able to stay out of the hospital for six months and was recently transplanted. That was a definite success!”

The data supports the anecdotal evidence, too. As a result of all the interventions, the 30-day readmission rates for the unit dropped from 54.2 percent in January 2016 to 29.2 percent in April 2017.