3032 — Adaptation and Implementation of an Evidence Based Intervention to Reduce Readmissions Following Major Abdominal Surgery

Naik AD, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center & Baylor College of Medicine; Campbell B, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center; Li LT, Baylor College of Medicine; Paasche-Orlow MK, Boston University Medical Center; Mills WL, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center & Baylor College of Medicine; Herman LI, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center & Baylor College of Medicine; Trautner BW, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center & Baylor College of Medicine; Anaya D, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center & Baylor College of Medicine; Berger DH, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E DeBakey VA Medical Center & Baylor College of Medicine;

Objectives:
About 16% of patients hospitalized for major bowel surgery are readmitted, often due to preventable, surgery-related conditions. Evidence based interventions exist to reduce medical readmissions, but have not been adapted for surgical admissions. This implementation study seeks to adapt the Project Re-Engineered intervention for bowel surgery including an After Hospital Care Plan (AHCP) that generates personalized materials from electronic medical records.

Methods:
We used a three phase design process to adapt the AHCP. First, we conducted a systematic review and meta-analysis to identify conditions associated with readmission following bowel surgery (ileus, surgical site infection, etc.). Second, a Delphi panel of surgical experts identified warning signs and symptoms most commonly associated with each of the top conditions in the meta-analysis results. Warning signs were iteratively assessed using health literacy and heuristic evaluation to craft a patient-centered AHCP. Finally, seven patients were interviewed, two weeks after undergoing surgery, to establish content validity and usability of the AHCP. A cluster analysis was performed after a card sorting task for each set of responses to specific usability questions. We identified themes from clusters of individual responses with representative quotes.

Results:
We identified 11 warning signs or symptoms that experts agreed were associated with conditions in our meta-analysis. The AHCP went through several revisions including conversion from doctor-centric to patient-centric terminology, reducing the reading level, and formatting into three heuristic based, action-oriented zones (green, yellow, red). Usability testing demonstrated comprehension of this three-level heuristic for warning signs and recognition of appropriate patient actions. Participants suggested edits to the design, readability, and formatting of certain pages.

Implications:
We adapted the AHCP for major abdominal surgery using the three-stage process of synthesizing best evidence, expert consensus, and direct user input. We are implementing this technology-enabled intervention on a surgical service to test its effectiveness on readmissions.

Impacts:
An intuitive, patient-centered after hospital care plan adapted for abdominal surgery has the potential to reduce unnecessary healthcare utilization following postsurgical hospital discharge.