Clinicians regularly face challenges delivering comprehensive psychological and medical care to patients with complex conditions, such as delirium, alcohol withdrawal, suicide risk, and potential harm to others (DASH). Although these problems can affect patients at any age, they are particularly common among the elderly.
Brigham and Women’s Hospital (BWH) has achieved measurable improvements in reducing readmission rates among this population with the development of a multidisciplinary effort led by the departments of medicine, nursing and psychiatry to improve care and outcomes for patients admitted as inpatients. David F. Gitlin, MD, Chief of the Division of Medical Psychiatry at BWH, was a key driver of this initiative.
“Some of the recurrent issues our patients presented with was this cluster of problems including delirium, alcohol use disorders, suicide risk and violence potential. As we are at an increased risk for higher-than-average readmission rates due to misdiagnosis, we focused our efforts on earlier detection and treatment,” Dr. Gitlin said.
Dr. Gitlin was an author of the Joint Commission Journal on Quality and Patient Safety titled A Population-Based Care Improvement Initiative for Patients at Risk for Delirium, Alcohol Withdrawal, and Suicide Harm (Jt Comm J Qual Patient Saf. 2015 Jul;41(7):291-302). Barbara E. Lakatos, DNP, PCNS-BC, APN, Program Director of the Psychiatric Nursing Resource Service at BWH and BWH hospitalist Adam Schaffer, MD, were co-authors.
In their publication, the BWH team reported that implementing an interdisciplinary care improvement initiative at BWH for patients at risk of negative outcomes related to certain mental or behavioral health conditions reduced the preventable 30-day hospital readmission rate of patients by nine percent over three years.
In an effort to reduce readmission rates caused by mental health problems, Dr. Gitlin and his colleagues used a comprehensive, population-based effort, implemented across all departments at BWH, to enhance screenings for these conditions. The DASH initiative involved enhanced screening and the introduction of new care management guidelines and order sets pertaining to the DASH diagnoses.
With the exception of neonatal and hospice patients, all BWH inpatients were included in the study. After screening and care guidelines were developed, the team embarked on a hospital-wide effort to integrate them into the clinical workflow in 2010. Training videos, resource manuals and role-playing workshops were developed and assessment tools were embedded into nursing and medical workflows. The effort started with pilot units and was later adopted across the entire hospital.
The care improvement process consisted of four phases: development of guidelines; implementation/rollout; integration into practice; and sustainability, including ongoing practice development and evaluation. The implementation outcomes were evaluated using eight parameters: acceptability; adoption; appropriateness; feasibility; fidelity: implementation cost; penetration and sustainability.
The assessment showed the volume, average length-of-stay, clinical service line, discharge location and 30-day admission rate of DASH patients. The researchers found that while the DASH population increased by one percent from 2012 to 2013, the 30-day readmission rate decreased by nine percent from 2010 to 2013 approaching the hospital’s overall rate of 13.3 percent.
Dr. Gitlin said, “A key reason for these positive results is that our DASH program was embedded in the clinical culture across the hospital. Close nurse-physician collaboration, including joint leadership and simultaneous rollout for nurses and physicians, contributed to the initiative’s effective implementation.”