A. V. Fisher5, S. A. Campbell-Flohr5, L. Sell4, E. Osterhaus4, A. W. Acher5, K. Leahy-Gross4, M. Brenny-Fitzpatrick4, A. J. Kind6, P. Carayon7, D. E. Abbott5, E. R. Winslow5, C. C. Greenberg5, S. W. Weber5 4University Of Wisconsin Hospital And Clinics,Madison, WI, USA 5University Of Wisconsin,Department Of Surgery,Madison, WI, USA 6University Of Wisconsin,Department Of Medicine,Madison, WI, USA 7University Of Wisconsin,College Of Engineering,Madison, WI, USA
Introduction: Readmission is common after complex abdominal surgery, occurring in up to 30% of patients. While transitional care protocols are effective at decreasing readmission for medical patients, there is no evidence-based protocol for surgical patients.
Methods: The Coordinated Transitional Care Protocol (C-TraC), initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol. Adaption was accomplished using a modified Replicating Effective Programs (REP) model developed by the Center for Disease Control. Hospital system characteristics, pre-existing resources and discharge processes, as well as clinical and social factors specific to surgical patients were first documented. Key-informant interviews were conducted with members of the medical C-TraC team, surgeons, nurses, and clinical team leaders in order to identify core elements of the pre-existing C-TraC protocol, align these elements within the health system and surgical context, and adapt the protocol with multi-disciplinary buy-in. Following this, specialized nurses were trained and the surgical C-Trac (sC-TraC) protocol was launched for high-risk surgical patients. Protocol refinement was accomplished by stakeholder meetings on a biweekly basis to perform rapid iterative adaptations.
Results: Pre-implementation planning through multi-disciplinary engagement allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. Findings from key-informant interviews led to several unique elements that were incorporated into the sC-TraC protocol, including pre-discharge identification of red-flag symptoms, a standardized list of questions for follow-up phone calls to detect complications, and identification of unique outpatient resources to manage complications as an outpatient. These elements were intended to specifically address surgical issues such as nutrition, fever, ostomy output, dehydration, drain character, and wound appearance. The protocol maintained elements such as a pre-discharge meeting and inpatient integration by the transitional care nurse. After sC-TraC launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. The program was received well by patients with only 3 of 297 (1.0%) patients refusing enrollment, and 278 of 294 (95%) enrolled patients reaching full engagement with post-operative phone calls. Survey results from a random patient sample showed 100% overall satisfaction with the transitional program.
Conclusion: This transitional care protocol is the first to be specifically adapted to surgical patients, which occurred using a modified REP model and resulted in multi-disciplinary buy-in, low refusal rates, and high patient engagement and satisfaction. This adaptive process could be used to implement transitional care protocols at other program sites.