With up to 3% of Medicare payments at risk for high readmissions rates in 2016, hospitals are intensifying their focus on ways to minimize patient readmissions within 30 days of discharge. Currently, the readmissions penalties apply for patients who were initially admitted for acute myocardial infarction, heart failure, pneumonia, exacerbations of chronic obstructive pulmonary disease (COPD), and patients admitted for elective total hip arthroplasty or total knee arthroplasty. In 2017, the covered conditions will also include coronary artery bypass graft surgery.
What can hospitals do to lower their readmissions rates? Several studies suggest that looking at internal processes and nurse staffing can significantly improve those rates.
A study in Medical Care found that improving nurses’ work environment can reduce readmissions for pneumonia, acute myocardial infarction and heart failure. After adjusting for patient and hospital characteristics, the researchers demonstrated that each additional patient in an average nurse’s workload increased the odds of readmission for heart failure by 7%, for AMI by 9% and for pneumonia by 6%. Receiving care in a good rather than a poor work environment, conversely, resulted in rates that were 7% lower for heart failure, 6% lower for AMI, and 10% lower for pneumonia.1
If a hospital with a “poor” work environment moved up to a “good” environment, its readmission rate would be expected to drop from the 84th to 50th percentile or from the 50th to 16th percentile among the hospitals studied. “A hospital that could change its work environment from poor to good and reduce nurse workloads from 6 to 4 patients per nurse would, all else being equal, see their readmission rates reduced from 25% to 21%," wrote the researchers.
Another study this spring found that missed nursing care independently predicts heart failure readmissions and that the quality of the nurse work environment significantly affects the incidence of omitted care. Previous research found that the most common reasons for missed care were labor resources, material resources and communication.2 Hospitals can address several of these factors by improving the material resources, including technological support, available to nurses.
- Automated reminders can help ensure that nurses provide the appropriate care at the right time.
- Electronic surveillance systems can flag patients who may have infections with highly contagious or multidrug resistant organisms, enabling nursing staff to quickly implement contact or isolation precautions, reducing workload associated with an outbreak while improving patient safety and outcomes.
- Electronic surveillance can also help nurses and nurse managers rapidly identify a patient whose health is deteriorating and appropriately prioritize patient care in real time.3
- Clinical decision support systems that include nursing care plans can reduce work required to develop and record those plans for patients.
- Integrated systems can improve communication by eliminating delays and ensuring nursing staff have the latest information and comments at the point of care.
McHugh MD, Ma C. Hospital Nursing and 30-Day Readmissions Among Medicare Patients with Heart Failure, Acute Myocardial Infarction, and Pneumonia. Medical Care. 2013;51:52-59
Kalisch BJ, Tschannen D, Lee Hyunhwa, Friese CR. Hospital Variation in Missed Nursing Care. American Journal of Medical Quality July/August 2011;26(4):291-299.
Glenister H. How real-time data can improve patient care. Nursing Times. September 23, 2015;III(39):15-16.