A tool to reduce unnecessary readmission to hospital

A well-known problem for this patient group

The problem with unnecessary readmissions to hospital for elderly , chronically ill and multi-diagnosed patients is well known within healthcare. Essentially, the issue is caused by the fact that the assessments of the patients after they have been released from hospital are done based on criteria for patients without pre-existing conditions, and by professionals in other contexts than the hospital which previously released them. In other words, the baselines used to assess, for example, the patients’ breathing, or oxygen saturation may be an unattainable one for patients in this group. This can cause healthcare staff to readmit the patient to hospital even when their health status is normal – considering the patient’s overall health situation and medical history.

The tool helps make more accurate assessments

A core issue to solve in this, is to improve the communication between the healthcare staff that the patient meets outside the hospital – for example nurses and other staff in nursing homes and clinics – and the physicians in the hospitals where they have been previously admitted. By using service design and co-creation methodologies, we have together with Østfold Hospital transformed their insights and ideas into a concrete communication tool which helps the physicians releasing the patient from hospital adapt the information to those who will meet the patient outside the hospital.

We designed a chart where vital signs can be assessed, based on the criteria for that specific patient, instead of generic criteria. This chart is completed by the physician responsible for signing the patient out from the hospital, and is sent with the patient, together with his or her medical records. Whenever the patient gets in contact with healthcare institutions outside the hospital, health care workers can look at the chart and correctly assess whether the numbers are "within" the normal reference range, to correctly assess whether or not the patient needs to be re-admitted to hospital. (The tool got its name - “Hva er innafor” – meaning “what is okay/normal” due to this.)

An improved patient experience and reduced costs

The chart makes it easier for nurses and other healthcare professionals to make accurate judgements of the patients’ health status, and that way we can avoid unnecessary stays in hospital. Being admitted to hospital is often stressful and can have a negative impact on these patients’ overall sense of well-being, which is why it’s important to avoid it whenever it’s not necessary. Moreover, there is a great potential in saving costs by reducing the re-admissions to hospital, as hospital admissions are costly affairs. By saving the hospital resources for when they are needed, we can provide better and more effective healthcare services.

Work in progress

The tool is already being used and tested by healthcare staff, but is still on a prototype stage. The plan is to develop and refine the tool further, and explore the potential to transform the analogue chart also into a digital tool.