LACE Readmission Risk
Plentiful evidence shows that patients with multiple comorbidities, frequent emergency room visits or other frailty indicators are more likely to present for urgent readmission to hospital within 30 days of their last discharge. Many such readmissions are preventable, mostly through anticipation, communication, and provision of post-discharge supports.
Connect Care Automated LACE Index Score
Most of the information needed to calculate a LACE Index is available to Connect Care in-system, and does not need to be entered by prescribers. Accordingly, an automatically calculated LACE Index is recorded and updated daily for all inpatients.
The automated LACE index score that is built into Connect Care discharge planning tools is based on the original basic "LACE readmission risk index." This is promoted for use in Canada to stratify patients into those who are at low, moderate or high risk for early readmission. The index considers the patient's length of stay (L), admission type (A), comorbidities (C) and frequency of emergency room visits (E):
Length of Stay (L)
Number of days spent in hospital, including day of admission and day of discharge, irrespective of level of care (e.g., alternate level of care). This automated calculation pertains to a patient's current inpatient encounter. It will be under-scored for patients transferred from one-facility to another as part of a single health condition episode (since the LOS clock re-starts for each new facility).Admission Type (A)
Acuity of admission reflects whether an admission occurs via the emergency room (including interfacility transfers) or via an elective admission bed. Given ongoing over-capacity challenges in Alberta inpatient facilities, virtually all inpatient encounters are organized via the emergency department and fit the LACE coding rules for an emergent admission. Automated LACE scores may be slightly inflated for elective surgury encounters that are initiated via an emergency department visit.Comorbidities (C)
A patient's comorbidity burden is guaged with an adaptation of the Charlson Comorbidity Index. This add points when specific health conditions, such as cerebrovascular disease, are present. Connect Care uses a patient's visit diagnosis, problem list and medical history to calculate the Charlson sub-score. Given that many Connect Care charts have incomplete or inadequate problem list and medical history management, automated calculations are most at risk for under-estimating the LACE Index and re-admission risk. Some comorbidity elements (e.g., "moderate or severe liver or renal disease") are not precisely defined and so prone to subjective bias over-estimation.Emergency Room Visits (E)
Points are added (up to 4) for emergency room visits, including ones that trigger a hospital admission, occuring in the prior 6 months. Connect Care is the record of care for all acute and emergency facilities in Alberta. Accordingly, this sub-score is accurate for patients who receive health care in Alberta. The automated sub-score will miss emergency room visits
There are other LACE instruments and versions. The "LACE+ Index", for example, may have better predictive accuracy than the basic LACE index. However, LACE+ adds many more attributes (e.g., "teaching status of discharge institution" and "case-mix group score") that are (currently) hard to automate in the Alberta context. A LACE+ score is available to Connect Care users. However, this is currently not integrated into discharge planning tools.
Manual Calculation
Flowsheet-based LACE and LACE+ calculators are available to use in addition to or instead of automated calculations. This allows users to independently assess things like comorbidity burdens.
The LACE pop-up report includes a link to a pop-up flowsheet that can be used to manually calculate a LACE Index. Manual calculations can help validate Connect Care's automated calculation. The LACE flowsheet is also available in the Flowsheets activity.
Location
The automated LACE Index can be found and used in a variety of ways:
Inpatient Chart Sidebar
A rightward sidebar is present when any chart is opened to an inpatient encounter. The default view includes "Checklists" as well as a "Transition Planning" section that includes the current LACE Index.
The sidebar has an index at the top, which includes an item for "Planning". This can be selected to bring more transition planning tools into the sidebar, such as the "Transition Planning" section that includes the LACE Index.
Rapid Rounds Patient List, Column and Report
Inpatient care teams may support Rapid Rounds with Connect Care tools that facilitate discharge planning. These include a Patient List template with columns summarizing key information affecting discharge readiness, including the LACE Index.
A "LACE Index" column can be added to any patient list. This column displays a patient's LACE score, colour-coded to indicate low (green), moderate (yellow) and high (red) risk. Hovering over the score reveals subcategory scores and double-clicking on the score opens a summary of details and implications for discharge planning.
Rapid Rounds lists typically show a "Rapid Rounds Report" when a patient row is selected. This report also displays LACE Index information.
The same Rapid Rounds report can be viewed from the Transition Planning section of the inpatient sidebar.
Discharge Summative Documents
LACE Index values are included in the Basic and Advanced provincially standardized discharge summary templates in the "Follow Up Arrangements" section.
SmartLink
A ".LACEINDEX" SmartLink can be used to pull LACE information into any inpatient documentation. The LACE index value and level is inserted.
A ".LACEINDEXFOLLOWUP" SmartLink may be more appropriate for discharge or transfer documentation. It pulls in the LACE risk level together with the AHS suggested post-discharge follow-up interval.
Interaction
All of the above LACE Index inclusions are interactive. Selecting the "LACE" label will open a pop-up display that contains information about how the index was calculated, what in-system data was used, and how the index might be interpreted to guide discharge planning.
Validity
The comorbidities component of the LACE Index calculation is sensitive to whether a patient chart complies with minimum use norms. It is essential that a patient's chronic illnesses be documented in the problem list and/or medical history sections of the chart. If a particular LACE Index seems inappropriately low, be sure to confirm that the patient's comorbidities are appropriately reflected in the problem list and medical history. The LACE pop-up report (accessed by selecting the LACE label wherever it appears) includes summaries of relevant in-system data.