Institutional experience with a limb salvage quality improvement initiative to reduce length of stay and readmissions

Abstract

Background

This article aims to outline the process and present preliminary outcomes of a local quality improvement initiative focusing on length of stay (LOS) and 30-day unplanned readmissions in patients undergoing treatment for peripheral arterial disease.

Methods

Initiating with internal data acquisition, our clinical informaticists, adept in Epic data mining, were tasked with monthly query of the database for all patients with peripheral arterial disease managed since May 2021. An automated report of crucial variables, eliminating the need for individual chart review, was thus generated. Studying trends in LOS and readmissions, we set target goals of 7 days for LOS and 11% for 30-day unplanned readmission, referencing the top-decile institutions in the Vizient ranking. To enhance our quality improvement initiative, we formed a comprehensive limb salvage committee, comprising a vascular surgeon, hospitalist, podiatrists, nurses, a case management team, and a clinical researcher. This multidisciplinary team met regularly to review monthly reports, identify trends, and propose improvements. After 6 months of observation, the limb salvage committee finalized a set of recommendations, which were then communicated to the vascular surgery faculty for feedback and subsequent implementation. Monthly outcomes were continuously monitored by the limb salvage committee to assess progress and pinpoint areas necessitating further improvement.

Results

Between May 2021 and March 2023, 985 consecutive procedures were performed. The average postoperative LOS was 7 ± 10 days, with 35% not meeting the goal. Patients not meeting the LOS goal often had a history of coronary artery disease or congestive heart failure and were admitted initially for nonvascular reasons. The readmission rate was 15%. Recommendations from the limb salvage committee included deferring nonurgent revascularization to outpatient care with prehabilitation for at-risk patients, and early follow-up by a nurse practitioner for wound check and pain management. These recommendations were implemented at the end of March 2023. After implementing these recommendations, 272 cases recorded between April and July 2023 saw a decrease in patients not meeting the target LOS to 27%, and unplanned readmissions decreased to 11%.

Conclusions

Our limb salvage quality improvement project has proved efficient in monitoring quality metrics and targeting specific areas in need of improvement. Continuous monitoring is necessary to ensure compliance, track outcomes, and identify areas in need of further improvement. Future studies will assess further the effectiveness of this process in improving patient care.