What Was Done
Identification of Local Problem
01/01/2022–12/31/2022 (pre-intervention)
- 27 ED visits or 6.3%
- MBSAQIP National Data Benchmark 8.4%
The main reasons for these visits were abdominal pain, poor oral intake, and nausea and vomiting. In general, these are usually preventable with outpatient IV fluids, instructions on how to eat and sip properly, and taking PRN nausea medication.
How Was the Quality Improvement (QI) Activity Put in Place
Context of the QI Activity
The goal is to reduce the incidence of ED visits in the first 30 days after metabolic and bariatric surgery by 50% by December 2023. We will accomplish this goal by increasing patient education about the post-op experience. Education includes post-op phone call, “bariatric safe over the counter medication” handout and “common complaints after surgery” handout. We will also establish a formal Outpatient IV Protocol to increase the opportunity for patients to receive outpatient IV fluids.
Our goal by providing these interventions is to identify early medical problems in a timely and efficient manner and direct patients to the appropriate resources to lower visits to the ED after bariatric surgery. It will also provide an opportunity to reinforce education that was provided prior to discharge. The main barrier identified in our teaching prior to discharge includes drowsiness from narcotics, anesthesia, and poor sleep in the hospital. By calling 24-48 hours after discharge, patients should be able to remember more with improved concentration. Also, it is another opportunity to educate because patients are often overwhelmed with the amount of information.
By addressing the main reasons patients visit the ER through our post-op discharge phone call, we can provide and reinforce education to notify the office of signs and symptoms of surgical site infection, poor oral intake, and nausea and vomiting. The MBS coordinator is also able to address any diet questions immediately post-surgery instead of the patient waiting to call.
Planning and Development Process
We will use the ACS Quality Framework to support our Plan, Do, Study, Act (PDSA) methodology.
Plan
- The MBS coordinator will be tasked with performing the post-op discharge phone call following the approved script.
- The MBS director will oversee the QI project.
- The MBS committee will provide insight and improvement initiatives if determined they are needed throughout the year.
- The MBS clinical reviewer will upload data into the registry.
- The goal is to reduce post-op ER visits by 50% by December 2023.
- Resources needed for this project are free besides the cost of printing handouts for patients but was determined by the committee to be doable.
Conduct
- Financial resources needed were minimal for this project
- Reducing preventable ER visits is important for the safety and overall satisfaction of the patients post-op.
Resources Used and Skills Needed
Staff
Team members included the MBS Director, MBS Coordinator, and the MBS Clinical Reviewer.
Costs and Funding Sources
Financial resources needed were minimal for this project (cost of printing handouts).
What Were the Results?
Overall Results and Analysis
01/01/2023–12/31/2023
- 9 ED visits or 2.5%
- MBSAQIP National Data Benchmark 9.2%
ED visits in the 30-day post-operative period after metabolic and bariatric surgeries reduced from 6.3% in 2022 to 2.5% in 2023. This is a reduction of 60.3% which surpassed our goal of 50%. This is likely related to the fact that many of the ED visits were indeed preventable with early intervention. The post-operative phone call was helpful in other ways as well to increase patient satisfaction and build a rapport with patients. Many times, the MBS coordinator got very positive feedback for “checking up” up on the patient.
An outpatient IV hydration protocol was created and implemented. This gave the clinic a standardized procedure to follow regarding patients that required IV hydration. Another outpatient IV clinic was identified to be used by our patients. In the past, if the hospital’s outpatient IV clinic could not accommodate our patients, we would have to send them to the ED for safety. This second clinic allows us to quickly treat our patients and prevent some ED visits. The data for IV outpatient fluids is difficult to interpret if a positive change was made. For example, in 2022, there were 6 patients that received outpatient IV fluids or 1.4%. In 2023, after the interventions were in place, still 6 patients received IV fluids outpatient or 1.6%. However, the data from the reason for ED visit shows a drastic improvement. In 2022, 4 out of 27 ED visits or 14.8% were due to nausea and/or vomiting and/or fluid electrolyte or nutritional depletion. In 2023, 0 out of 9 ED cases were due to nausea, vomiting and/or fluid electrolyte or nutritional depletion. That is a great difference! This change may be due to the ability of the MBS coordinator to intervene quickly if a patient was not getting enough oral fluid. The post-operative phone call allowed an opportunity to encourage oral intake by really emphasizing the importance of it.
Findings from this QI initiative suggest that a post-operative phone call by a healthcare professional may reduce the number of ED visits post metabolic and bariatric surgery.
Limitations
- 97% of patients received a post-op phone call. Occasionally, an individual’s voicemail box was not set up to leave a voicemail. At one time, the MBS coordinator had a family emergency and completed the calls at a later date than 24-48 hours post-surgery. 79.4% of patients answered the MBS coordinator’s post-operative phone call, which leaves 20.6% of those who did not answer. A voicemail was left for those who did not answer, but 20.6% of patients did not call back. In retrospect, more education could have been provided to patients to expect a phone call because the MBS coordinator’s phone number is different than the BMI office phone number. Patients were provided the MBS coordinator’s phone number multiple times, but maybe there was a better way to provide this education to get more people to answer. An email probably could have been sent as well, but it was decided with people being drowsy and fatigued after surgery, a phone call was the best option.
- Patients were instructed to track fluid intake but did not always follow through. The MBS coordinator had to try to calculate how many ounces the patient drank after listing the fluids they consumed. An educated guess had to be used at times to determine if a patient needed outpatient IV fluids.
- Due to the size of the hospital, the QI initiative data is relatively small (273 total post-operative calls), so it is difficult to know if these interventions could be replicated nationwide with similar results.
Tips for Others
Lessons Learned
During the QI initiative, a need for further post-operative education was identified and a “Common Complaints after Surgery” handout was created. This handout gave the patient the autonomy to try to correct mild post-operative complaints like constipation, nausea, and gas pain while still emphasizing that the patient should call the office for further help or go to the ED for emergencies. This provided reassurance on what is “normal” after surgery and eased a lot of the patients’ anxiety.
