Surgical readmissions: Results of integrating pre-, peri- and postsurgical care

Aims To explore the feasibility of recruiting surgical oncology patients and implementing a surgical integrated discharge (SID) programme led by advanced practice providers (APP). Background Burden of illness and complexity of treatment regimen makes it challenging for surgical oncology patients to participate in research. Surgical oncology nurses may have the necessary expertise to overcome this problem. Design Controlled longitudinal prospective observational study. Methods The SID programme included multidisciplinary care coordination, regular communication among APPs and proactive postdischarge follow-up. Administrative databases were used to identify matching historical controls (n = 113) and evaluate programme outcomes. Results Patient enrolment was 84%. The main challenges for the programme implementation included incompatible health information systems among care settings, variation in care processes among hospital units and need for provider behaviour change. Conclusions Most surgical oncology patients are willing to participate in outcomes programmes when contacted by familiar clinical personnel but programme implementation requires leadership support, communication among care teams and training and infrastructure.