studies

HEPATOLOGY, VOLUME 62, NUMBER 1 (SUPPL) AASLD ABSTRACTS 473A
26% to 19%. Paracentesis and thoracentesis increased, 12%
to 20%. Conclusion: Elderly subjects with CLD present with
more comorbidities, more complicated liver disease, higher
prevalence of NAFLD rather than viral hepatitis, higher procedure
utilization and substantial inpatient mortality. The epidemiology
of CLD in the elderly is changing and warrants chronic
disease management models to mitigate the burden expected
to be borne by Medicare.
Disclosures:
The following authors have nothing to disclose: Michael Hagan, Maria A. Kouznetsova,
Sumeet K. Asrani
529
Communication, sequence and system modeling of GI/
Hepatology outpatient and inpatient work flows for targeting
clinical decision support tools
Anne Miller 3,4 , Jejo D. Koola 3,4 , Michael E. Matheny 3,4 , Julie
Ducom 1 , Jason M. Slagle 4 , Erik J. Groessl 1,5 , Sterling M. Dubin 1,2 ,
Freneka F. Minter 3,4 , Jennifer H. Garvin 6,7 , Matthew B. Weinger 4 ,
Samuel B. Ho 1,5 ; 1 VA San Diego Healthcare System, San Diego,
CA; 2 Medicine, University of California, San Diego, San Diego,
CA; 3 VA Tennessee Valley Healthcare System, Nashville, TN;
4 Vanderbilt University, Nashville, TN; 5 University of California,
San Diego, San Diego, CA; 6 VA Salt Lake City Healthcare System,
Salt Lake City, UT; 7 University of Utah, Salt Lake City, UT
Objectives: Increasing numbers of cirrhotic patients have high
re-admission and mortality rates. Interventions that improve
care coordination with well-targeted clinical decision support
(CDS) can improve outcomes. We analyzed work processes
in outpatient and inpatient settings to identify opportunities for
CDS placement. Methods: Ethnographic observations, guided
by user-centered design principles, occurred at two VA medical
centers. Within 24 hours, pairs of experienced observers met
to interpret their notes. The debriefings elucidated the structure
and meaning of work as practiced resulting in: 1) Affinity diagrams
to aggregate interpreted themes, insights & intervention
design ideas; 2) Communication models to elucidate information
flows across roles; 3) Sequence models to define work
in goal-oriented terms, and 4) Artifact analyses to elucidate
cognitive & problem solving structures. Results: At Site A, 26
physicians, 3 nurses and 1 clerk were observed in: 1) gastrointestinal
(GI) outpatient clinics (31%); 2) inpatient medical
rounds (69%). At Site B, 14 physicians were observed in: 1)
GI outpatient (14%) & Primary Care clinics (29%); 2) Emergency
Department (21%); 3) inpatient medical rounds (29%)
and 4) inpatient GI consult rounds (7%). 2/3 of participants
were trainees & 1/3 were attending physicians. We categorized
168 and 147 notes, respectively, during debriefings
into 3 major themes each with several sub-themes. Team and
Care Coordination addressed work allocation among local
and distributed providers. Alerting and Reviewing addressed
information access and retrieval so as to confer meaning to
patients’ situations. Executing patients’ plans-of-care addressed
the implementation of clinical goals & tasks. We identified
resident physicians as the primary vertical and horizontal communication
and coordination hubs. Using artifact analyses we
found that residents’ paper patient printouts most effectively
supported their clinical work. Using sequence analysis we identified
patient assessment & planning as critical resident tasks
to be targeted for CDS interventions (e.g., automated dashboards,
data visualization, diagnostic and therapeutic checklists).
Conclusions: The success of quality improvement depends
on how well interventions are integrated into routine work.
This study identified 4 intervention design goals to enhance
cirrhosis care: 1) interventions should assume distributed work
environs; 2) target residents; 3) integrate CDS with clinical
assessment & planning processes rather than global point of
order entry; and 4) be provided in both electronic & hardcopy
forms. The design/integration of specific CDS tools is ongoing.
Disclosures:
Samuel B. Ho - Grant/Research Support: Genentech, Gilead; Speaking and
Teaching: Prime Education, Inc
The following authors have nothing to disclose: Anne Miller, Jejo D. Koola,
Michael E. Matheny, Julie Ducom, Jason M. Slagle, Erik J. Groessl, Sterling M.
Dubin, Freneka F. Minter, Jennifer H. Garvin, Matthew B. Weinger
530
Reduction of 30 day Readmission Rate in Patients with
End Stage Liver Disease
Simona Rossi 1 , Manisha Verma 1 , Catherine Reynolds 2 , Dee Morrison
2 , June Smith 2 , Cindy Mcglone 1 , Eyob L. Feyssa 1 , Victor J.
Navarro 1 ; 1 Medicine, Albert Einstein Medical Center Philadelphia,
Philadelphia, PA; 2 Nursing, Albert Einstein Medical Center Philadelphia,
Philadelphia, PA
BACKGROUND: Patients with end stage liver disease (ESLD) are
a unique population prone to high hospital readmission rates,
as evidenced by a 37% thirty day readmission rate (Volk M,
2012) compared to a 20% readmission rate in the Medicare
population of patients excluding those with liver disease. AIM:
We tested an intervention designed specifically for patients with
ESLD, intended to reduce 30 day readmission rates. METHODS:
Using tools described in the evidence based literature for non-
ELSD as a starting point, a liver specific discharge process was
developed comprising 1) patient and family centered nurse
administered medication training for adherence and side effect
monitoring accompanied by performance feedback to assure
understanding, 2) salt and free water restriction counseling,
and 3) 48 hour post-discharge scripted telephone interviews
for symptom and medication side effect monitoring, and follow
up adherence. This process was implemented in June 2014.
Nurses were educated to perform these interventions. Positive
findings (e.g.; new symptoms) reported during the phone interview
were managed with pre-determined responses, including
electronic alerts to a physician for immediate intervention.
Mean paired differences were compared for 30 day readmission
rates during the six month period prior to implementation
of the process, following a standard discharge process, and for
the six months after implementation of the new discharge process.
As this was a quality improvement exercise, all patients
admitted to the Inpatient Liver Unit of the Einstein Medical Center,
Philadelphia, were included. Results: The mean (SD) 30
day hospital readmission rate for the six month period prior
to implementation was 30.18(6.76), compared with 21.83
(8.3) following implementation (p=0.19). Conclusion: In the
ESLD population, strategies to reduce hospital readmissions