1. A Quality Improvement Initiative Decreases 30-day Readmission Rates in Patients Admitted to a Hepatology Service Elliot B. Tapper, Michelle Lai Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA A teaching hospital of Harvard Medical School  The rate of readmission for patients with complicated cirrhosis is high at BIDMC and around the country  More than 600 patients are admitted with complicated cirrhosis each year with a baseline readmission rate of 36%  Interventions to reduce readmissions contribute to cost savings and improved patient quality of life.  Ensuring that patients with hepatic encephalopathy receive intensive treatment may reduce readmissions Aim/Goal: Problem: Description of the Intervention Results/Findings to date: Key Lessons Learned Next Steps For More Information, Contact Elliot B. Tapper; etapper@bidmc.harvard.edu  We aimed to reduce readmission rates for patients with cirrhosis and achieve compliance with quality care standards  Standard treatment of hepatic encephalopathy (universal treatment with rifaximin and high dose lactulose)  Standard treatment of spontaneous bacterial peritonitis  Standard prophylactic measures to prevent deep vein thrombosis and variceal hemorrhage.  Deployed in Phases: Standards to be delivered by a checklist (at first) and later using modifications to the electronic ordering system (electronic phase)Deployed in Phaseschecklistelectronic  Measurement: Analysis of outcomes, adjusting for known confounders with statistical support (Dr. Murray Mittleman) provided by the Shapiro Center for Education. Data provided by Gail Piatkowski (decision support). We compared our 30-day readmission statistics to the BIDMC hospitalist group and the liver service of a regional quaternary care hospital  The rate of readmission for patients with complicated cirrhosis is high and modifiable  A checklist intervention with electronic decision support is a strong quality improvement tool but electronic decision support appears superior to hand-held checklists  Ensure that patients can obtain the medications prescribed as inpatients on discharge (liaise with case management, pharmacy)  Develop an intervention to reduce the risk of renal failure  Disseminate this knowledge to other liver centers Clinic here to lern more about the development of this intervention Clinic here to lern more about the development of this intervention The decline in readmissions was driven by a reduction in readmits for encephalopathy The 30-day readmission rate declined and this change was specific to our service, compared to the BIDMC hospitalist serve and OSH liver service For a deeper look at our population’s clinical characteristics, click here For a deeper look at our population’s clinical characteristics, click here

2. The Checklist

3. Electronic Phase Acute hepatic encephalopathy is treated with aggressive ‘goal- directed’ lactulose Chronic hepatic encephalopathy Is treated in the usual fashion with a PRN dose and flag to notify an MD if the mental status changes A B To combat underdosing of ceftriaxone for SBP, clinicians must chose the indication for ceftriaxone and then the computer presets a 2 gram dose

5. “Table 1”