Abstract WMP94: Root Cause Analyses of Preventable Causes of Readmission after Stroke: The University Hospitals- Case Medical Center (UH-CMC) and University Hospitals System Stroke Program (UHSSP) Experience

Abstract

Root Cause Analyses of Preventable Causes of Readmission after Stroke: The University Hospitals- Case Medical Center (UH-CMC) and University Hospitals System Stroke Program (UHSSP) Experience Objective: Metrics, such as the 30 day readmission rate after stroke, are increasingly used by consumers and payors to reflect hospital quality of care. Benchmarks determined by large administrative databases lack detailed root cause analyses which are crucial in determining preventable causes. Methods: In 2010, the UHSSP Quality Initiative developed a MIDAS™ report alerting the Stroke Coordinator of all inpatient encounters to any UH hospital within 30 days of a stroke discharge from UH-CMC. A focus study guided a detailed case review including demographics, index admission stroke subtype, discharge treatment and disposition, follow up appointments, medical compliance, readmission diagnosis and location, and Root Cause Analysis of preventable causes. Results: Of 1093 stroke discharges from January 2011 - June 2012, 84 (7.7%) were readmitted within 30 days; 5.7% to UH-CMC and 2% to other UH hospitals. During this period, compliance with evidence-based guidelines for stroke exceeded benchmarks. Readmitted patients were 54% female, 30% aged ≥ 80 years and 45% were transferred from facilities. Stroke subtypes reflected total discharges with 78% ischemic stroke, 9.6% TIA, 8% intracranial hemorrhage and 3.6% subarachnoid hemorrhage. Of the various causes of readmission, the most common were recurrent vascular events in 22% (TIA, stroke 14%, myocardial 8%) and infection in 20% (pneumonia 11%, urinary tract 7%). Bleeding complications of anti-thrombotic therapy occurred in 8% (hemorrhagic transformation 6%, GI 2%). Other frequent events included new onset seizure (7%) or cardiac arrhythmia (5%). Scheduled, elective readmissions accounted for 6% and medically unnecessary transfers from facilities an additional 6%. Conclusions: Single center data would have missed 26% of the readmissions that went to hospital system community hospitals. Root Cause Analyses of readmitted patients discovered evidence relevant to the readmitting diagnosis prior to index hospital discharge in 7% but only 6% of all readmissions were preventable by the discharging team.