APRN-Led Discharge Program Reduces Readmission Rates Following Treatment With Immune Checkpoint Inhibitors

Sap Partners | Cancer Centers | <b>The University of Texas MD Anderson Cancer Center</b>

APRNs developed a discharge program which reduced readmission rates for patients receiving immunotherapy for advanced melanoma.

An advanced-practice RN (APRNs) led discharge education and follow-up program reduced the readmission rate for patients with melanoma who were treated with immune checkpoint inhibitor (ICI) therapy. The findings of the program were published in the Clinical Journal of Oncology Nursing.

In the pre-initiative setting (n = 32), 11 patients needed to be readmitted because of an ICI-related toxicity. However, post intervention (n = 13), no patients were readmitted because of an ICI-related toxicity.

“Hospital readmissions are negatively associated with health care quality and costs,” Michelle L. Rohlfs, DNP, APRN, FNP-BC, AOCNP, an advanced practice RN at The University of Texas MD Anderson Cancer Center in Houston, wrote in the study. “Because of the nature of the disease and treatments, readmissions are high in patients with cancer, often occurring within the first few weeks of discharge.”

According to Rohlfs, this evidence-based is 1 strategy to reduce unplanned readmissions for patients with immune-mediated treatment toxicities.

The initiative was based out of the Melanoma Medical Oncology department at The University of Texas MD Anderson Cancer Center, where many patients seek treatment for advanced melanoma. According to Rohlfs, many patients will receive ICI therapy, which typically occur in the outpatient setting. If a significant toxicity occurs, then patients will be admitted to the inpatient setting to treatment with high-dose intravenous steroids. To be eligible for discharge, patients need to be able to transition to oral steroids and be able to continue steroid tapering setting. Close monitoring and concise patient education is key throughout this process to safeguard against readmission.

The department had a 30-day readmission rate of 22%, which was above the institutional goal of 10%. Thus, APRNs working in the department developed and implemented a structured patient discharge program to help improve readmission rates for these patients.

A literature review revealed that most hospital readmissions occur within 7 to 10 days of discharge, and that patients who received ICIs are at a greater risk for readmission because of these agents posit a high risk of immune-mediated toxicities. It also showcased that high-quality discharge programs can reduce readmission rates as they improve care transitions, and that nurse-led follow-up telephone call programs have been effective in reducing readmissions.

To that end, APRNs created a teaching program for patients who were admitted to the impatient unit with an immune-mediated toxicity. As per the program, patients received daily education while still in impatient setting regarding their specific toxicity and signs to look out for. Once they were discharged, the APRN followed-up with phone calls on days 3, 6, and 9. Each phone call lasted approximately 30 minutes, and APRNS would use the American Society of Clinical Oncology guidelines to help guide patients thought symptom management over the phone.

The discharge teaching tools included and administration and daily checklist, a day-of-discharge checklist, post-discharge telephone follow-up script.

The administration and daily checklist included the following protocols:

  • Identify the caregiver.
  • Identify where the patient will return upon discharge.
  • Instruct the patient or caregiver on the practice of using the whiteboard to write down questions. The care team writes down goals of care.
  • Distribute special immune-mediated toxicity education to the patient or caregiver (eg, National Comprehensive Cancer Network education).
  • Give verbal education regarding the patient’s diagnosis.
  • Discuss discharge goals and progress.
  • Identify any homecare needs. Arrangements should be made with the team if needed (eg, physical or occupational therapy, case management, social work).

The day-of-discharge checklist outlined the following protocols:

  • Distribute the Quality of Discharge Teaching Scale to the patient or caregiver.
  • Discuss postdischarge follow-up telephone calls.
  • Medication teaching and reconciliation should be completed the day before or day of discharge.
  • Discuss patient questions.
  • Review the patient’s condition, including the continuation of care in the outpatient setting and warning signs to monitor after discharge.
  • If the caregiver is not in the hospital, discuss via telephone and address further questions.
  • Discuss follow-up appointments with the oncology team and specialty services, if applicable.
  • If home care is needed, arrange it before the discharge date.
  • Place all discharge teaching information in the after-visit summary.
  • Provide contact information for the healthcare team.

Lastly, the post-discharge follow-up script included the following questions:

  • How are you feeling?
  • Do you have any questions regarding your recent hospital stay?
  • Do you have all your medications?
  • Do you have any questions about how to take your medications?
  • Do you have any questions about the discharge instructions given to you during the hospitalization?
  • Do you know when your follow-up visit is with [insert medical oncologist name]?
  • Were you given a follow-up visit with [insert specialty service]? (if applicable)
  • Do you have any issues with keeping your follow-up appointments?

Rohlfs noted that the 12-week implementation period was a short period and may not be the breast representative sample. Moreover, the sample size was also small, decreasing the generalization of the findings.

Also, according to the study, APRNs shared that this implementation was time-consuming, as their routine tasks were not decreased. However, as the benefit of the program was clear, study authors suggested timing the calls to occur on days 4 and 10 post discharge and aligning the phone call times to occur during steroid completion.

“This quality improvement initiative illustrates how APRNs can be instrumental in providing high-quality discharge teaching in oncology, which supports institutional and nursing efforts to reduce avoidable readmissions,” Rohlfs concluded.

Reference

Rohlfs ML. Decreasing readmission rates in patients with immune-mediated toxicities using an APRN-led discharge teaching program. Clin J Oncol Nurs. 2022;26(6):659-663. doi:10.1188/22.CJON.659-663