Optimizing Discharge After Shorter Hospitalizations: Lessons Learned Through After-Hours Calls with Thoracic Surgical Patients

Abstract

Objective Minimally invasive procedures coupled with enhanced recovery pathways enable faster postoperative recovery and shorter hospitalizations. However, patients may experience unexpected concerns after return home, prompting after-hours calls. We aimed to characterize concerns prompting after-hours calls to improve discharge strategies. Methods A single-institution, retrospective review was conducted of thoracic surgical patients from 11/4/2019 to 6/14/2020. Records were reviewed and elements of patient demographics, surgical procedures, postoperative courses, reasons for calls, and outcome of calls were collected. We compared characteristics of patients who made after-hours calls to those who did not, and performed multivariable analysis to identify characteristics associated with making an after-hours call. Results During the study period, 379 patients underwent thoracic surgical procedures, among whom 88 (23.2%) initiated after-hours calls. Of these, 62 (70%) addressed patient symptoms, while 26 (30%) addressed patient questions including drain management, medications, and hospital policy questions. Patients making after-hours calls more frequently had undergone complex operations (26.1% vs 8.2%, P = 0.001), and were less likely to have received a standardized, clinician-initiated post-discharge telephone follow-up (29.5% vs 54.3%, P < 0.001). Complex operations increased likelihood of after-hours calls (OR: 3.33, 95% CI: 1.69-6.57, P < 0.001), while receipt of clinician-initiated telephone follow-up decreased likelihood of after-hours calls (OR: 0.38, 95% CI: 0.22-0.64, P < 0.001). There were no differences in emergency visits between the 2 groups (11% vs 8%, P = 0.370). Conclusions Despite efforts to optimize patient symptoms and knowledge prior to discharge, a substantial number of patients still have concerns after discharge. Many after-hours calls are related to knowledge gaps that may be addressed with improved predischarge education. Moreover, clinician-initiated telephone follow-up shows benefit in reducing after-hours calls.

Framework, component, and implementation of enhanced recovery pathways

“…Post-discharge surveillance is an important part of the pathway, as patients may have additional care needs once home [ 108 ]. A survey indicated that the post-discharge telephone checkup was valued most highly out of all ERAS components postoperatively [ 109 ], follow-up calls aided in answering unexpected questions patients had post discharge (despite prior attempts to optimize knowledge) [ 110 ] and relieving the isolation faced by patients ‘left alone with their illness’ [ 111 ]. Active post-discharge surveillance programs are cost-effective, as postoperative issues may be resolved in the outpatient setting thereby reducing readmission or emergency department presentation [ 112 ].…”

Commentary: Optimizing resources in lung cancer survivorship

“…We have employed this model using problem-focused postdischarge telephone calls to identify patients who are at higher risk for emergency department visits and readmissions. [2][3][4] In our experience, many issues during the early postoperative period can be managed by nurses over the telephone, whereas more complex issues have been referred either to the clinic or emergency department. The survivorship model described by Keshava and colleagues 1 shows how health care resource utilization can be optimized beyond the immediate postoperative setting.…”