Improving estimation of proportion of readmissions among patients with liver cirrhosis and associated complications on the gastroenterology ward, Mulago hospital.

Abstract

ABSTRACT Background. Hospital managers are increasingly focusing their attention on reducing rates of rehospitalization as a way of improving quality of care and reducing costs. At Mulago hospital, there is limited information on readmissions and complications of cirrhosis to inform planning of the necessary strategies to improve the quality and efficiency of patient care during hospitalization and subsequent follow-up visits. Methods. This was a cross-sectional study incorporating quality improvement (QI) methods during the data collection process. The QI methods included process mapping, root cause analysis, Plan-Do-Study-Act cycles and education of the Gastroenterology ward QI team. During the intervention period, 591 files of discharged patients were reviewed and data from the face sheets of these files were abstracted using a data extraction tool. Results. Inadequate supervision was a root cause of inadequate documentation. During the education period, there was waxing and waning in level of knowledge of the QI team that corresponded with changeover of intern doctors. A similar trend was noted in the level of completion of face sheets. Intensified supervision of interns by Senior House Officers and physicians greatly increased the level of completion. Cirrhosis accounted for 33.7% of documented diagnoses and the proportion of readmissions among patients with cirrhosis was 21.6%. The most common documented complications of cirrhosis among readmitted patients were ascites, portal hypertension with or without variceal bleeding and hepatic encephalopathy at 74.4%, 62.8% and 27.9% respectively. Conclusions. Inadequate supervision was a root cause of inadequate documentation on the face sheets. Intensified supervision of interns greatly improved completion of face sheets. One in every five patients admitted with cirrhosis on the GI ward of Mulago hospital is a readmission. This was considered an improved estimate in view of the documented process measures. The most common complications among readmitted patients were ascites followed by portal hypertension with or without variceal bleeding, hepatic encephalopathy and hepatocellular carcinoma. Recommendations. The interventions to improve care of patients with cirrhosis should target management of ascites, portal hypertension, hepatic encephalopathy and hepatocellular carcinoma. Physicians should intensify supervision of SHOs and interns to ensure that a diagnosis and its complications are written on the face sheet.