Using Post-Discharge Telephone Follow-Up by Nephrology Nurses to Reduce 30-Day Readmissions and Post-Discharge Complications for Adult Patients on Hemodialysis.

Hospital readmissions are responsible for considerable health care costs. About 35% of patients with end stage renal disease (ESRD) who are hospitalized are readmitted within 30 days of discharge (United States Renal Data System, 2017). Studies point to the considerable percentage of readmissions that are preventable through effective discharge planning and patient follow-up after discharge (Mistiaen & Poot, 2006). Telephone follow up is a high-quality, low-cost method of providing discharge follow up. This project examined the effectiveness of an evidence-based quality improvement process in providing post-discharge telephone follow up to adult patients on hemodialysis by experienced nephrology nurses through standardized unit workflow and leveraging of the electronic medical record (EMR). Results indicated a lower percentage of admissions from the emergency department (59.9% pre- vs. 55.4% post-intervention) and a lower percentage of 30-day readmissions (28.4% pre- vs. 24.6% post-intervention).

The Interdisciplinary Team and the Patient: Working Together to Achieve Buy-In for a UF Rate Less Than 13 mL/Kg/Hr.

The Centers for Medicare & Medicaid Services (CMS) metric for reporting ultrafiltration (UF) recommends limiting UF at a range of 10 to 13 mL/Kg/Hr to avoid organ stunning. All organ stunning has an impact on patient quality of life (QoL). As this new standard of UF is implemented, the interdisciplinary team (IDT) and the patient must work together toward achieving a less than 13 mL/Kg/Hr UF buy-in. Understanding the CMS goals and target date of January 1, 2018, for data collection purposes was key to early initiation of staff and patient education. Dialysis treatment centers must rise to implement mandated fluid removal objectives. Education and knowledge are the best facilitators of success when implementing change. The IDT must work together to continually reinforce the standards set by CMS.