Decreasing 30-day Readmissions for Pleural Effusions after Lung Transplant

Abstract

<h3>Purpose</h3> Pleural effusions (PEF) after lung transplant (LT) are a common cause of early readmissions, leading to patient suffering and increased cost. We conducted a quality improvement intervention to reduce 30-day readmissions for PEF after LT by 50% over six months. <h3>Methods</h3> We determined the baseline conditions of 30-day readmissions for PEF among patients transplanted in 2018 and 2019 at our institution. Then, we analyzed clinical, laboratory, and radiological data and interviewed LT providers to identify root causes. Finally, we explored countermeasures, implemented targeted interventions from March to September 2020, and tracked monthly performance. <h3>Results</h3> At baseline, 16/115 (14%) patients were readmitted within 30 days, 7/16 (44%) for PEF. CT scans at week 2 and 4 after LT were done in 108 (93%) patients. At week 2, 75 (69%) had small PEF and 1 (1%) had moderate PEF. At week 4, 70 (65%) had small PEF and 9 (8%) had moderate or large PEF. PEF enlarged in 5/7 (71%) patients readmitted for PEF compared to 1/9 (11%) patients readmitted for other causes, and 3/92 (3%) not readmitted. We identified enlarging PEF as a root cause for readmissions. We implemented an ultrasound intervention to assess PEF size at discharge, volume status, feasibility of increasing diuresis, and need for PEF drainage. During the intervention, 30/42 discharged patients (71%) had ultrasound. Monthly ultrasound performance increased from 57% to 75-100%. Ultrasound prompted PEF drainage before discharge in one patient. PEF enlargement was detected in 2/38 patients (5%) in CT scans. Four patients had ultrasound to reassess PEF after discharge. Seven patients (16%) were readmitted within 30 days, one (14%) for PEF. Two patients had small PEF on ultrasound and CT scan but were not the cause of their readmissions. <h3>Conclusion</h3> Small PEF are common after LT, yet only a subset enlarge and lead to 30-day readmissions. While better understanding of PEF development after LT is needed, ultrasound at discharge is feasible and allows timely interventions to decrease readmissions.