Quality Improvement: Decreasing Length of Stay and Readmission Rates for Bone Marrow Transplant Patients

We used the Plan-Do-Study-Act (PDSA) quality improvement methodology to decrease the average length of stay (ALOS) and readmission rates within 30 days for bone marrow transplant patients

June 1, 2011 through November 15, 2012 was chosen for baseline data (pre-implementation).  Changes in workflows, per PDSA methodology,  were implemented on November 16, 2012 including: a streamlined admission process, pre-transplant education in the outpatient rather than inpatient setting, improved anti-emetic strategy, and a consistent, protocol driven TPN use and taper.

We studied the effects to these changes through August 31, 2013 (post-implementation). We also reviewed patient satisfaction surveys during the same intervals.

The proportion of autologous to allogeneic transplants pre- and post-implementation was similar pre- and post- implementation (72% and 75% autologous). The ALOS (95% CI) for autologous transplant patients decreased from 21.03 (19.66 – 22.40; n = 72) to 18.54 days (17.63 – 19.46; n = 59).  ALOS for allogeneic patients decreased from 33.63 (29.61 – 37.62; n = 28) to 26.05 (23.56 – 28.55; n = 19).  

The overall 30-day readmission rate decreased from 6% to 2.56%; autologous from 1.39% to 1.69%, while allogeneic decreased from 17.69% to 5.26%.  TPN utilization decreased from 60.00% to 39.74%, and the average number of days on TPN was 11.43 and 8.42, respectively.

Overall, the Patient Satisfaction Index (PSI) increased from 90.36% to 93.57%.  Improvements were noted in the following domains: pre-BMT education, BMT inpatient care, discharge and teaching materials, and transition to referring physician. 

Discussion

The implementation of these changes led to a decrease in ALOS, readmission rates TPN use, and an increase in patient satisfaction.

These changes have important implications.  Reduced LOS is economically desirable, reduces infection risk and is liked by patients.  Similarly, less TPN use reduces risk of complications such as infection and hepatic dysfunction. 

Our experience illustrates the ability of PDSA methodology to make a quick change that can have significant impact, in a relatively short amount of time.