Bridging the Gap in the Continuum of Care for Spine Surgery Patients: A Quality Improvement Project

Abstract

<p>The purpose of this paper is to discuss the inadequate communication between patient settings and the practice settings, review the literature regarding communication and risks of readmission for spine surgery patients, and present an intervention for this problem using the PDSA cycle. The change in practice included a literature review to identify patients who were at high-risk for complications after surgery and readmission. Patients were identified with the use of the operative schedule and chart reviews and those that were identified were communicated using secure email or face-to-face hand-off to the inpatient Clinical Outcomes Leader (COL). Prior to the initiation of project, 30-day readmission rate mean was 7.4 percent and after the first month of project implementation, the rate decreased to 2.2 percent. Many components of the first PDSA cycle were successful but need to be modified for optimal compliance and success. Some patients were not identified when they were in the office for their pre-operative visit or when they signed their surgical consent. Communication between the RN Patient Navigator (RNPN) and the COL was positive in providing effective patient hand-off. Clinical Nurse Leaders (CNL) are leaders of healthcare teams of a microsystem and assess for the need for changes in practice. The project outcomes were successful and contribute to the importance to nursing practice, the role of the CNL, and healthcare in general.</p>