The Centers for Medicare & Medicaid Services (CMS) engages hospitals across the country to improve Patient Safety and Quality and achieve lower costs.  The goals include reducing unnecessary readmissions by 20% and avoidable harm by 40%. 

Effingham Health System (EHS) has spent the past nine months working diligently on reducing its readmissions and falls.  The Georgia Hospital Association recently published our story of success in these areas.  Please read further to learn more.

When beginning work on the Hospital Engagement Network initiative, it was decided to make reducing readmissions a priority. Our readmission rate for 2011 jumped up from 2.78% in 2010 to 4.91%. Initially, changes were made to implement a more thorough patient education process, beginning with those patients with congestive heart failure and pneumonia. In October of 2012, we then introduced this improved education protocol to all patients admitted and for all diagnoses.

When a patient is admitted and then diagnosed with either congestive heart failure or pneumonia, the system informs our staff to begin the protocols that have been put in place which includes providing the patient with much more information and educational material and instruction upon discharge. Additionally, we have instituted a follow-up phone call system in which case managers make contact with each inpatient within three days their discharge.  Case managers ask questions about the patient’s current state of health, and reinforce the information that was provided to the patient at the time of discharge. All of the information that is discussed during the follow-up phone call is placed into a separate flow chart that can be extracted and flow through our reporting system, as well as to the appropriate members of the patient’s care team.

Effingham Care Center, our skilled nursing facility that is located on the EHS campus, has been working with us on this important initiative as well. When a patient is admitted to the hospital’s inpatient unit from the Care Center, nursing staff makes sure that proper education is given to not only the patient; but also, to the Care Center nursing and ancillary staff.  This too helps to prevent readmissions. Now, our readmission rate for 2012 is down to 3.99% overall and our rate of preventable readmissions is down from 2.10% in 2010 to 0.49% in 2012.

The second priority initiative for EHS was to reduce the number of falls for our patients.   Our major emphasis was on making sure that each patient is assessed for fall risk, initially upon admission, and also daily during each shift. By having this protocol in place, it allows our nursing team to adjust patient interventions as needed and based upon each individual assessment. Some of the interventions put into place include the implementation of “full non-skid socks” and adhesive green stars which are placed on the doors of our patient rooms in cases where a patient is deemed to be a fall risk upon their initial assessment.  Additionally, our team conducts hourly rounding which ensures the “Four P’s” – Pain, Toileting (Potty), Positioning, and Prior to leaving the room asking the patient “is there anything else I can do for you?” This process serves as a reminder to our patients that someone will always be checking-in on them and this also helps to reduce the likelihood that the patient will attempt to stand and walk on their own.  Our hourly rounding protocol for care has had a direct and positive impact on the reduction of falls.

Finally, at EHS, we have an established Electronic Medical Records system and within the system, a provision that automatically sends our hospital’s therapy department a notification of any patient that meets the required score on the falls risk assessment. Doing so ensures that our therapy staff is adequately informed and prepared if and when the patient arrives at therapy. This system also provides the staff in our therapy department with the information necessary to help them determine whether or not an order for evaluation and/or treatment needs to be obtained from the patient’s PCP (primary care physician).

For 2012, there have been no reported falls since January 1st and based on the number of inpatient days, we have determined that our Falls Rate is at 0.26% for the year, down from 0.45% in 2010.

All of us are working to provide the highest standards of care at Effingham Health System. We are very proud of our accomplishments and it is with great pride that we know the community benefits from this as well. We want to do what is best for the patients and these measures reflect our commitment.


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