Postdischarge ICI Patient Education Eliminates Hospital Readmissions

The melanoma medical oncology (MMO) department at the University of Texas MD Anderson Cancer Center had a 22% 30-day readmission rate for patients experiencing immune-related adverse events (irAEs) from their ICI therapy, which was above the institutional goal of 10%. Many readmissions were caused by irAEs such as colitis, hepatitis, or nephritis. To improve care delivery and prevent avoidable readmissions, Rohlfs developed and implemented (https://doi.org/10.1188/22.CJON.659-663) a structured patient discharge program and telephone follow-up process. Rohlfs used the Plan-Do-Study-Act method (https://www.ahrq.gov/health-literacy/improve/precautions/tool2b.html) as a framework to create and implement the program.

Develop the Plan

Rohlfs conducted a literature review to ground her plan in the latest evidence to reduce readmissions. She found that (https://doi.org/10.1188/22.CJON.659-663):

• Most readmissions are for treatment toxicity and occurred within 7–10 days of discharge.
• Use of specialty services and high-quality, structured discharge programs can decrease 30-day readmissions.
• Nurse- and provider-led postdischarge follow-up telephone calls can decrease readmissions.

Create the Program

Rohlfs designed the program for adult patients (aged 18 years or older) who were treated with an ICI and admitted to the inpatient unit for an irAE. Under her process (https://doi.org/10.1188/22.CJON.659-663):

• Discharge planning begins during the first 24 hours of patient admission.
• The advanced practice RN (APRN) provides daily inpatient education tailored for their specific irAE and recommendations from the National Comprehensive Cancer Network’s 2022 Guidelines for Patients: Immunotherapy Side Effects: Immune Checkpoint Inhibitors.
• At discharge, the APRN provides postdischarge symptom education (e.g., what symptoms warrant notifying the healthcare provider) and the pharmacist provides medication teaching (e.g., instructions on steroid taper and other necessary immunosuppressive medications).
• All of the education and contact information is documented in the after-visit summary for patients and caregivers to use as a reference at home.
• The APRN facilitates postdischarge follow-up telephone calls using a telephone script with open-ended questions to identify issues.

Measure Its Results

During the 12-week study period, 13 patients completed the program and none were subsequently readmitted within 30 days of discharge. When compared to the 23 patients who had been admitted with ICI-related irAEs in the weeks before she initiated the program, 11 of whom had been readmitted within 30 days (47.8%), Rohlfs said (https://doi.org/10.1188/22.CJON.659-663) that the reduction was statistically significant.

On post-discharge surveys, patients also reported high satisfaction (https://doi.org/10.1188/22.CJON.659-663) with the program, rating its content an average of 9.42 and its ability to meet their needs an average of 9.92 on a 0–10 scale.

Evaluate for Continued Enhancement

“APRNs were able to provide specialized patient education while simultaneously providing medical intervention,” Rohlfs said (https://doi.org/10.1188/22.CJON.659-663). “This eliminated the need for the patients’ problems or concerns to be escalated to another provider, such as the on-call physician, and eliminated the need to go to the emergency department.”

She said that (https://doi.org/10.1188/22.CJON.659-663) implementation was highly feasible. It aligned with the department’s goals, used its existing infrastructure, and required no additional resources or costs. Additionally, the APRNs encountered no barriers when adopting the new discharge program into their established workflow.

“An evidence-based discharge program focused on patient and family engagement, effective communication, and toxicity management is one strategy to reduce unplanned readmissions for patients with immune-mediated treatment toxicities,” Rohlfs concluded (https://doi.org/10.1188/22.CJON.659-663). “This quality improvement initiative illustrates how APRNs can be instrumental in providing high-quality discharge teaching in oncology, which supports institutional and nursing efforts to reduce avoidable readmissions.”

Learn more about Rohlfs’ program by reading the full Clinical Journal of Oncology Nursing article (https://doi.org/10.1188/22.CJON.659-663). Explore ONS’s Immuno-Oncology Learning Library (https://www.ons.org/learning-libraries/immuno-oncology-immunotherapy) for nursing resources on ICI therapies. Get insight on implementing evidence-based practice change by reading the best practices and lessons that two ONS members learned as they implemented their own programs in ONS Voice’s 2021 practice change feature article (https://voice.ons.org/news-and-views/practice-change-transform-cancer-care-through-quality-improvement-and-evidence-based).