Reducing Re-admissions of Patients After Heart Surgery Through After-the-Operation Follow-up
Heart surgery is a major procedure that requires careful recovery and follow-up to prevent complications and improve outcomes. However, many patients who undergo heart surgery are readmitted to the hospital within 30 days of discharge, which is associated with adverse outcomes and significant healthcare costs. According to a systematic review and meta-analysis of 53 studies, the pooled 30-day readmission rate after coronary artery bypass graft (CABG) surgery was 12.9% . The most common causes of readmission were infection, sepsis, cardiac arrhythmia, congestive heart failure, respiratory complications and pleural effusion . These readmissions are often preventable and indicate gaps in the quality of care during the transition from hospital to home.
Therefore, it is important to implement effective strategies to reduce re-admissions of patients after heart surgery through after-the-operation follow-up. These strategies can be classified into three categories: pre-discharge interventions, post-discharge interventions and bridging interventions .
Pre-discharge interventions are aimed at preparing the patient for a safe and smooth transition to the home environment. They include patient education, discharge planning, medication reconciliation and scheduling a follow-up appointment. Patient education involves providing information about the diagnosis, treatment, recovery process, self-care, warning signs, lifestyle modifications and medication adherence. Discharge planning involves assessing the patient’s needs, preferences and resources, and arranging for appropriate services and support at home. Medication reconciliation involves reviewing the patient’s medication list, ensuring accuracy and consistency, and addressing any potential drug interactions or errors. Scheduling a follow-up appointment involves making sure that the patient has a timely visit with their primary care provider or cardiologist after discharge.
Post-discharge interventions are aimed at monitoring the patient’s condition, providing ongoing support and addressing any issues or concerns that may arise after discharge. They include follow-up phone calls, communication with ambulatory providers, home visits and telemonitoring. Follow-up phone calls involve contacting the patient within 24 to 72 hours of discharge to check on their symptoms, medication adherence, self-care behaviors and any problems or questions. Communication with ambulatory providers involves sharing relevant information about the patient’s hospitalization, discharge plan and follow-up needs with their primary care provider or cardiologist. Home visits involve sending a nurse or other health professional to the patient’s home to assess their clinical status, provide education, reinforce self-care instructions and coordinate care. Telemonitoring involves using devices or applications to remotely measure and transmit the patient’s vital signs, symptoms or other data to a health care provider for review and feedback.
Bridging interventions are aimed at facilitating continuity of care and enhancing coordination between different settings and providers. They include transition coaches, patient-centered discharge instructions and clinician continuity. Transition coaches are specially trained nurses or other health professionals who provide individualized guidance and support to the patient throughout the transition process. They help the patient understand their condition and treatment plan, identify and address barriers to self-care, advocate for their needs and preferences, and communicate with their health care team. Patient-centered discharge instructions are written summaries of the patient’s diagnosis, treatment, medications, follow-up appointments, self-care instructions and contact information for their health care team. They are tailored to the patient’s literacy level, language and cultural background. Clinician continuity involves ensuring that the patient sees the same clinician or team of clinicians during their hospitalization and after discharge.
Evidence suggests that these strategies can be effective in reducing re-admissions of patients after heart surgery. For example, a study by Cleveland Clinic found that cardiac rehabilitation therapy — which includes exercise training, nutrition counseling and stress-reduction techniques — reduced 30-day readmission rates by 25% . Another study by PLOS One found that post-discharge interventions such as home visits and telemonitoring reduced 30-day readmission rates by 22% . A third study by ACC found that a navigator program — which involved a team of nurses, social workers and pharmacists who provided pre-discharge education, post-discharge phone calls and home visits — reduced 30-day readmission rates by 28% .
In conclusion, reducing re-admissions of patients after heart surgery is a clinical priority that can improve both the quality of life for patients and the financial wellbeing of health care systems. By implementing effective strategies such as pre-discharge interventions, post-discharge interventions and bridging interventions, health care providers can ensure a safe and smooth transition from hospital to home for patients who undergo heart surgery.
Works Cited
: Shawon MSR et al., “Patient and hospital factors associated with 30-day readmissions after coronary artery bypass graft (CABG) surgery: a systematic review and meta-analysis”, Journal of Cardiothoracic Surgery, 2021, https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-021-01556-1.
: Alper E et al., “Hospital discharge and readmission assignment help – research paper writing service “, UpToDate, 2023, https://www.uptodate.com/contents/hospital-discharge-and-readmission.
: “Cardiac Rehab Key to Preventing Patient Readmissions”, Consult QD, 2017, https://consultqd.clevelandclinic.org/cardiac-rehab-key-to-preventing-patient-readmissions/.
: Zhang Y et al., “Strategies to prevent hospital readmission and death in patients with heart failure: a systematic review and network meta-analysis”, PLOS One, 2021, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249542.
: “Patient Navigator Team Successful in Improving Patient Outcomes”, ACC, 2019, https://www.acc.org/latest-in-cardiology/articles/2019/02/14/12/06/patient-navigator-team-successful-in-improving-patient-outcomes.
