Preliminary Report on Home Nurse Visits for Prevention of Readmission for Dehydration following Bariatric Surgery

Linden A Karas, MD1, Shannon Schultz, MD1, Madhu Siddeswarappa, MD1, Stephen D Slane, PhD2, Prashanth Ramachandra, MD1, Adam Goldenberg, MD1. 1Mercy Catholic Medical Center, 2Cleveland State University

Introduction: While bariatric surgery lowers overall health care costs, high readmission rates have insurance companies questioning its cost effectiveness. Studies led by J. Saunders (2008), B. Hong (2012), and T.A. Kellogg (2009) have shown readmission rates of 0.6%-24.2% following bariatric surgery at high volume centers. The most common preventable cause of readmission is dehydration caused by nausea/vomiting and abdominal pain. Mercy Bariatrics in Philadelphia, PA, designed an innovative home nursing program to assess for early signs and symptoms of dehydration during the first month following bariatric surgery. Upon diagnosis, nursing initiates treatment with home intravenous fluid infusion or refers refractory or severely dehydrated patients to the hospital for further evaluation and treatment. The goal is to decrease 30-day hospital readmissions.

Methods: Mercy Bariatrics, a community hospital-based Bariatric Center of Excellence is currently enrolling all eligible bariatric surgery patients into a prospective study that examines readmission outcomes for patients followed by home health care nurses for one month post-operatively. The following is a preliminary analysis of those patients enrolled in the study between January 2014 and August 2014, compared with a retrospective sample of patients who underwent surgery between May 2012 and August 2013 and were not followed by home nurses. A Chi-square test compared overall 30-day readmission rates and 30-day readmission rates due to dehydration before and after implementation of the home nursing program.

Results: Through a survey of medical records including 393 past bariatric patients, the all-cause hospital readmission rate was 14.3% within 30 days of bariatric surgery, with dehydration accounting for 46% of these admissions. A preliminary analysis of 30-day hospital readmissions following the implementation of the home nursing program yielded a 13.8% all-cause readmission rate with dehydration accounting for 26.6% (N=94 patients assessed). Five of the enrolled patients were found to be dehydrated; two of these received home hydration, and one was able to avoid hospital readmission due to this treatment. The other three dehydrated patients were referred directly to the hospital for evaluation. Though the rate of readmissions due to dehydration is trending down by approximately 30% (6.6% pre-enrollment compared to 4.3% post-enrollment), there is no statistically significant difference in all-cause readmission rates (p=0.646) or readmissions due to dehydration (p=0.545) after implementation of the home nursing program.

Conclusions: The preliminary analysis shows a trend towards decreased 30-day hospital readmissions after implementation of the home care program, but it was not statistically significant. At this early date, the power of the study is low. Further enrollment over the next two to three months is needed to make this finding significant. The study is also limited because home hydration was not attempted with all dehydrated patients. However, home hydration will become more common as the visiting nurse service expands over the next several months. Increasing use of home hydration and larger enrollment numbers may show that home nurse visits can decrease readmission rates for dehydration, and thereby decrease health care costs.

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