Challenges of Care Transition From Hospital to Home for Older Colorectal Surgery Patients: Surgeons’ Perspectives

To synthesise and describe the combined evidence from systematic reviews of interventions using elements from the Transitional Care Model, on the content and timeframe of the interventions and the related improvement of outcomes for older patients with multiple chronic conditions. The population of older patients with multiple chronic conditions is increasing worldwide and trajectories are often complicated by risk factors. The Transitional Care Model may contain elements to support transitions between hospital and home. An umbrella review. A comprehensive search in five electronic databases was performed in April 2021 based on the search terms: 'Patients ≥60 years,' 'multi-morbidity,' 'Transitional care model,' 'Transitional care,' and 'Systematic review.' PRISMA guidelines was used. Five systematic reviews published from 2011 to 2020 comprising 62 intervention studies (59 randomised controlled trials and three quasi-experimental trials) were included in the review. The synthesis predominantly revealed significant improvements in decreasing re-admissions and financial costs and increasing patients' quality of life and satisfaction during discharge. The results of the review indicate that multiple elements from the Transitional Care Model have achieved significant improvements in older patients' transitions from hospital to home. Especially a combination of coordination, communication, collaboration and continuity of care in transitions, organised information and education for patients and pre-arranged structured post-discharge follow-ups. The transition from hospital to home is a complex process for older patients with multiple chronic conditions. A specific focus on coordination, continuity, and patient education should be implemented in the discharge process. Nurses with specialised knowledge in transitional care are needed to ensure safe transitions. The umbrella review is part of a larger research program which involved a patient expert advisory board, which participated in discussing the relevance of the elements within the umbrella review.

608 Background: Cirrhotic patients with localized colorectal cancer are potential candidates for tumor resection. The aim of this review was to evaluate the morbi-mortality after colorectal surgery. Methods: Comprehensive search was conducted using PUBMED, EMBASE, and the COCHRANE Library. Prospective and retrospective studies were selected. The study population included cirrhotic patients who underwent colorectal resection for non-metastatic colorectal cancer and patients with benign and other malignant disease. The postoperative morbi-mortality and independent risk factors were analysed. Results: Eight studies were identified. Among these, four studies compared the risk of colorectal surgery in patients with and without liver cirrhosis. The number of patients varied from 41 to 6,120. The severity of cirrhosis in most of the studies was classified with the Child-Pugh score. Class B and C were observed in 20% to 60% of the patients. Sepsis represented the main postoperative complication and occurred in 48% to 77% of patients. Mortality varied according to the Child-Pugh score, ranging from 11% to 41%, and was significantly higher for patients with cirrhosis in Child-Pugh Class C. Urgent surgical procedure had a negative impact on prognosis. The average length of hospital stay ranged from 9 to 18 days. Cirrhosis was associated with a 2-3 time and a 4-10 time increased risk of postoperative mortality in the absence and presence of portal hypertension, respectively compared with non-cirrhotic patients. The independent risk factors for postoperative morbidity and mortality were encephalopathy, ascites, low haemoglobin, prolonged prothrombin time, elevated bilirubin, hypoalbuminemia, postoperative infection, total colectomy, elective or non-elective surgery, the presence of co-morbidities and MELD score ≥ 15. Conclusions: Colorectal cancer surgery is associated with an increased risk of postoperative morbidity and mortality in cirrhosis patients. Studies evaluating exclusively the operative risk for colorectal cancer surgery in this patient’s population are rare. Prospective controlled trials to optimize the perioperative management of those patients are needed.

Transitional care (TC) models are used to reduce adverse outcomes and hospital readmissions. This article reviews the scholarly literature to identify TC models that have been used successfully in patients with stroke. Literature in CINAHL, PubMed, and the Cochrane Database of Systematic Reviews from January 2000 to June 2013 was searched using the keywords "transitional care," "discharge planning," "care-coordination," "continuity of care," "follow-up after discharge," and "stroke." Web sites of established TC models were also reviewed to identify additional studies meeting review criteria. To be included in the review, studies must have been written in the English language and focused on adult patients aged 19 years and older with stroke, discharged from the hospital or acute rehabilitation facility to home. TC interventions were defined as those that employed one or more of the National Transitions of Care Coalition intervention categories: medication management, transition planning, patient and family engagement or education, information transfer, follow-up care, healthcare provider engagement, or shared accountability across providers and organizations (National Transitions of Care Coalition, 2011). The author examined the title and abstract of each study for eligibility against stated criteria. Thirteen articles representing 11 studies were found to meet the inclusion criteria. In the identified studies, TC was compared with usual care; however, what constituted usual care was not consistently elucidated. Fewer than half of the studies reported significantly improved results on selected outcomes. Across all the studies, TC did not result in a reported significant decrease in emergency department visits or hospital readmission rates. There was substantive heterogeneity in (a) intervention providers, (b) interventions used in TC, and (c) measures of outcome identified. Six of the 13 studies were identified as having successful interventions. Some evidence exists to support positive outcomes using TC in patients with stroke. Standardization of interventions and outcome measures is needed to determine the most effective interventions. Additional large-scale randomized, controlled trials should be undertaken to provide reliable data regarding effective TC interventions for persons after stroke.

The predictive value of preoperative frailty screening for postoperative outcomes in older patients undergoing surgery for non-metastatic colorectal cancer

ObjectiveSuboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm...

In this Perspective, we contend bold action is needed to improve transitions from hospitals to home for aging patients and their family caregivers living in rural and underserved areas. The Caregiver Advise, Record, Enable (CARE) Act, passed in over 40 US states, is intended to provide family caregivers of hospitalized patients with the knowledge and skills needed for safe and efficient transitions. It has broken important ground for family caregivers who assist with transitions in patient care. It may fall short, however, in addressing the unique needs of family caregivers living in rural and underserved areas. We contend that to realize the intended safety, cost, and care quality benefits of the CARE Act, especially for those living in rural and underserved areas, states need to expand the Act’s scope. We provide three recommendations: 1) modify hospital information systems to support the care provided by family caregivers; 2) require assessments of family caregivers that reflect the challenges of family caregiving in rural and underserved areas; and 3) identify local resources to improve discharge planning. We describe the rationale for each recommendation and the potential ways that an expanded CARE Act could reduce the risks associated with transitions in care for aging patients.

IntroductionDespite advances in innovation to improve patients’ transition experiences, it is unclear—in the context of colorectal surgery—what elements of patient education and care could provide the greatest benefit to patient...

Introduction : Stroke is a life threatening medical emergency that occurs suddenly and impact greatly in all aspect of an individual’s normal life since the early stage to long term. Various types of transitional care models are using by Health systems to improve care transition among stroke patients. Aims:
 This paper aims to explore the existing transitional care models used to improve the quality of care and patient’s outcome among stroke survivors.
 Methods: An Integrated review was conducted of empirical literature available in PubMed, Google Scholar, ProQuest, and NepJol by June 20, 2022 to identify studies of hospital to home care transitions of stroke patients with quality of care as the primary outcome.
 Results: There are 6 main types of transitional care model which focused on care transition for stroke survivors: 1) Naylor’s Transitional Care Model (TCM), 2) Coleman’s Care Transition Interventions (CTI), 3) Project Re-engineered Discharge (project RED), 4) Better Outcomes by Optimizing Safe Transition (Project Boost), 5) Enhanced Discharge Planning Program and 6) Comprehensive Post- Acute Stroke Services (COMPASS). Although, all models are differing by design, each of the models can provide a framework for managing health conditions from hospital to home settings in collaboration with the client and his/her family. Hence, the transitional care Models are effective in bridging the care gap between hospital to home and improve the quality of health care and patient outcomes among stroke survivors.

Medication errors: What is the pharmacist’s role?

IntroductionCatheter-associated urinary tract infection (CAUTI) is a relatively common cause of postoperative morbidity in colorectal surgery patients. It has been associated with increased length of stay and mortality.MethodsWe performed a retrospective cohort study of 620 colorectal surgeries to assess the prevalence of CAUTI and its relationship with preoperative and operative factors. We also sought to identify its association with postoperative outcomes.ResultsWe found that CAUTI occurred in 20.6% of colorectal procedures. We found that CAUTI was associated with older patient age, female gender, higher BMI, higher American Society of Anesthesiologists (ASA) classification, lower hemoglobin, higher creatinine, lower albumin, urgent procedures, bilateral ureteric stent placement, usage of double-J (DJ) stents, postoperative abdominal sepsis, and perioperative steroid usage. CAUTI was also associated with the presence of underlying medical conditions such as hypertension, ischemic heart disease, chronic kidney disease, cerebrovascular disease, and diabetes. With regards to postoperative outcomes, it was associated with postoperative stroke, myocardial infarction, prolonged length of stay, Intensive care unit stay, and mortality.ConclusionCAUTI remains a significant cause of morbidity in colorectal patients. Our patient population had a significantly higher risk of CAUTI compared to other series. Though sometimes labelled a minor postoperative complication, its occurrence is associated with other more significant postoperative complications, including death.

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Diabetes is a common chronic condition among adults that can complicate the transition from the hospital to the community. Hospital readmission is an important contributor to total medical expenditures and is an emerging indicator of quality of care. Failure to acknowledge diabetes transition of care is associated with increased emergency department visits and 30-day readmissions. Literature review of transition of care models, sample tools and processes are presented. Updated guidelines and recommendations aiming to identify and address risk factors for readmission of patients with diabetes are provided. Increased attention has been given to different aspects of diabetes care in regards to discharge planning. This includes early initiation of a discharge plan identifying readmission risk factors at time of admission. In addition, involvement of patients, families, care givers, health care providers and institutions to establish transitional care. Utilization of hospital resources includes medication reconciliation, diabetes education, care coordination, discharge planning, follow up appointments and post discharge care. Addressing transition of care is not a choice but an important quality of care marker. The transition of care determines where patients with diabetes will follow up and how payers will remunerate hospitals for management of diabetes during hospitalization, discharge planning process and readmission rates. Different transition of care models have been identified, utilized and evaluated. However, more research needs to be done to establish standardized transitional care guidelines specific to this population.

The occurrence of venous thromboembolism (VTE), manifesting as deep vein thrombosis (DVT) or pulmonary embolism (PE), after colorectal cancer surgery in Asian patients remains poorly characterized. The present study was designed to investigate the incidence of symptomatic VTE in Korean colorectal cancer patients following surgery, and to identify the associated risk factors. We retrospectively analyzed data from patients who developed symptomatic VTE after colorectal cancer surgery between 2006 and 2008. Deep vein thrombosis was diagnosed with Doppler ultrasound or contrast venography, and PE was identified with lung ventilation/perfusion scans or chest computed tomography. Thromboprophylaxis, including low-molecular-weight heparin, graduated compression stockings, and intermittent pneumatic compression, was used in patients considered at high risk of VTE. Of the 3,645 patients who underwent colorectal cancer surgery, 31 (0.85%) developed symptomatic VTE. Of those 31 patients, 23 (74.2%) had DVT, 16 (51.6%) had PE, and 8 (25.8%) had both. Two patients died from PE. Univariate analysis showed that a history of VTE, pre-existing cardiovascular disease, respiratory disease, transfusions, postoperative immobilization time, and postoperative complications were associated with VTE (p < 0.05 for each). Multivariate analysis showed that a history of VTE, pre-existing cardiovascular disease, postoperative complication, advanced cancer stage, and postoperative immobilization time were risk factors for developing symptomatic VTE. The mean hospital stay was 18.3 days, and the mortality rate was 6.5%. The incidences of symptomatic DVT and PE were found to be not low in Asian colorectal cancer surgery patients compared with Western countries. The risk factors for VTE were a history of VTE, pre-existing cardiovascular disease, postoperative complications, advanced cancer stage, and postoperative immobilization. Thromboprophylaxis should be strongly considered in patients with these characteristics. Large prospective randomized controlled trials should be conducted to further evaluate the risk of VTE in Asian patients, and to determine the optimal prophylaxis.

This study aimed to develop and evaluate a communication tool to guide transitional care for older patients. Using experience‐based co‐design, a communication tool resulted from the triangulation of data collected from three study phases. From 2015 to 2016, semi‐structured interviews and co‐design focus groups were undertaken with older patients, carers and healthcare practitioners across acute, rehabilitation and community settings. The evaluation phase, conducted in 2017–2018, involved use of the communication tool by healthcare practitioners in a multidisciplinary care team with older patients in acute care and semi‐structured interviews with healthcare practitioners about the acceptability and feasibility of the tool. A total of 103 patients, carers and healthcare practitioners took part. In semi‐structured interviews, patients and carers reported needing to become independent in care transitions, which was supported by discussing the transitional care plan with healthcare practitioners. Interviews with healthcare practitioners identified that their need for fast and safe care transitions was supported by team discussion and by engaging patients and carers in their transitional care plan. Co‐design focus group participants identified principles guiding transitional care including patient‐centred communication. Data collected from semi‐structured interviews and co‐design focus groups were used to develop a prototype communication tool to guide conversations about discharge care between healthcare practitioners and older patients. Following use, healthcare practitioners reported that the communication tool was feasible and acceptable although some nurses perceived that transitional care was not their role. The communication tool provides an evidence‐based resource for ward nurses to support transitional care continuity in multidisciplinary models.

Centre conducting review Pace University Lienhard School of Nursing in collaboration with the New Jersey Centre for Evidence Based Nursing: A Collaborating Centre of the Joanna Briggs Institute, University of Medicine and Dentistry of New Jersey School of Nursing, Newark, USA Review Objective The objective of this systematic review is to synthesize the best available research evidence on effectiveness of patient-caregiver dyad discharge learning need interventions on 30-day hospital readmissions of elderly patients (65 years or older) with community acquired pneumonia? Since the primary focus is on assessment of learning needs of the patient-caregiver dyad as central to interdisciplinary coordination of care and discharge planning, studies consistent with this primary focus will be included in the review. Studies that are beyond the scope of this review and will be excluded will be those that focus on the provision of pneumonia care during hospitalization and those in which discharge planning is focused on treatment modalities for pneumonia. Review Question What is the effectiveness of patient-caregiver dyad discharge learning needs interventions on 30-day community hospital readmissions for elderly patients (65 years or older) with community acquired pneumonia? Background Community acquired pneumonia (CAP) is the most common cause of death from infection in the United States and leads to 1.7 million hospital admissions1,2 Among patients 65 years and older, CAP is one of the leading causes of mortality 3. Elderly patients with CAP, have a 12% mortality rate within thirty days post discharge4. Higher mortality rates among elderly patients are associated with premature discharges, inadequate teaching for the patient-caregiver dyad and hospital readmissions3,5. CAP is defined as a pneumonia not acquired in a hospital or a long term facility. CAP is diagnosed by pulmonary infiltrates seen on chest radiograph with clinical notation in medical record of “pneumonia” on admission to hospital.1,2,6. Re-admission of patients 65 years and older due to CAP is also associated with increased hospital expenditures 3,6. In the U.S., 42% of the national healthcare budget is spent on inpatient care, and readmissions account for one quarter of Medicare inpatient expenditure 7,8. In the U.S., hospital incentive payment plans are directly linked to thirty-day re-admissions rates for CAP and length of hospital stay 4. In 2007, the Medicare Payment Advisory Commission (MedPAC) estimated approximately 18 percent of hospital admissions result in readmissions within 30 days, costing the Center of Medicaid Services $15 billion9. In the U.S., readmission to hospital within thirty days following hospitalization for CAP is a process measure utilized by the Center for Medicare Services (CMS) to evaluate discharge planning outcomes. 6-8. In this review, unexpected readmission is defined as the subsequent emergency or unplanned admission of the discharged patient to any hospital setting within thirty days following hospitalization for CAP. Internationally, decreased length of hospital stays has intensified care in the hospital and shifted rehabilitation to the home environment. The need for discharge planning among elderly patients is becoming increasingly important as both the aging population and increased longevity affect the demand for inpatient hospital services. In the U.S., older adults are responsible for 38% of all hospital discharges 10. Strunk, Ginsburg & Banker 11 projected that by 2015, persons aged 65 and older will account for 14.5% of the American population and utilize 7.6% more inpatient resources. Among the elderly population, effective discharge planning that supports their social network can reduce hospital readmissions 12,13. In a systematic review of the literature, Archie & Boren 14 advanced that the hospital discharge process is poorly standardized and is characterized by discontinuity and fragmentation of care possibly associated with lack of coordination in the handoff from the hospital to community care, social support gaps, high rates of low health literacy, and poor delineation of discharge responsibilities among hospital staff. Coleman, Parry, Chalmers, & Min 15 reported communication deficits during the discharge process adversely affected quality of care in 25% of post hospitalization visits. Therefore, the discharge process is an opportunity to markedly improve communication between health providers, patients and caregivers. Current literature regarding best practices in reducing readmission rates for pneumonia reflects a body of literature studying antibiotic choice, timing of antibiotic administration and disease specific care coordination (i.e. pneumonia vaccination) 1,2, 16-18. Discussion of the discharge process among adult patients and their caregivers has been generally infrequent 12. Nolan, Grant, Keady, & Lundh19 reports a scarcity of articles related to caregiver support and adult patients. Upon discharge, care needs extend beyond discharge into the home where the burden of managing the complexities of recovery falls on the patient and family members20, 21. The partnership between caregiver and care receiver is addressed in this review as the patient-caregiver dyad. Nursing literature has identified caregiver involvement as a potential variable in unplanned hospital readmissions among adult patients22-24 Expanding current evidence suggests that deficiencies in the quality of care can be improved by patient-centered practices that coordinate discharge planning with patients and caregivers 14-16, 22. Coleman et. al25 defines patient-centered coordination of care as a process which improves patient outcomes undergoing transitions in care (i.e. discharge from hospital to home). Horowitz & Chassin2 demonstrated improved patient education decreased length of stay and hospital readmission rates for adult pneumonia patients. The Institute for Healthcare Improvement (IHI) and Robert Wood Johnson Foundation outlined enhancing teaching and learning as a key component of an ideal discharge from hospital to home. In a national program Transforming Care at the Bedside26, IHI suggested identifying the family caregivers and patient learning needs on admission. Moreover, the patient education process should be redesigned to improve the patient's and family caregivers' understanding of the disease process. In nursing literature, there is growing demand for comprehensive discharge planning that reflects a need for effective communication between health providers and family caregivers throughout hospitalization 13, 22, 27-30. Naylor et al. 28 found that discharge planning that directly involved elderly patients and their families resulted in fewer readmissions, decreased length of stay, and lower readmission costs for medical patients. There is also increasing evidence to suggest that a patient's readiness for discharge and caregiver comprehension of hospital discharge instructions may be associated with lower hospital readmission rates in adult patients aged 65 and older with CAP 2,30. The literature related to family caregivers' readiness for patient discharge refers to the caregiver's need for specific information on discharge 22,31. Haesler, Bauer, & Nay 32 identified lack of staff initiation of family education as an area of dissatisfaction for caregivers. In 1991, a nursing literature review addressed the need for research regarding the topic of education for the nonprofessional caregiver 5. Moreover, lack of involvement of family caregivers due to inadequate learning assessment has been identified in nursing literature as early as 1995 33. In a randomized control trial of 363 patients, a comprehensive discharge plan that included an assessment of caregiver learning needs and burden demonstrated reduced readmission rates among elderly patients 34. Chow, Wong, & Poon 35 demonstrated in a convenience sample of 47 families that enhanced discharge planning including caregiver education is essential for families of stroke victims. Although caregivers are viewed as important in discharge planning research, a November 2009 integrative review of 36 articles found advanced practice nursing interventions that included care coordination and transition care promising in a decrease in readmissions 10. The effects of discharge planning on unscheduled readmission rates in adult populations discharged from hospital to home has been systematically reviewed in the Cochrane Library of Systematic Reviews 36. The effectiveness of interventions aimed at the patient-caregiver dyad during discharge planning has not been systematically reviewed in the Cochrane Library of Systematic Review, CRD DARE or in the Joanna Briggs Institute Library of Systematic Reviews. It is important to systematically review this innovation's impact on the patient-caregiver dyad including other patient centered care components (i.e. caregiver support). Inclusion Criteria Types of participants This review will consider studies that include adult patients aged 65 and older in hospital settings diagnosed with community acquired pneumonia (CAP). Types of interventions The review will consider studies specific to assessment of patient and caregiver/family learning needs related to discharge education. Types of outcomes This review will consider studies that include the following outcome measures: coordination of care, unexpected hospital readmissions within thirty days. Types of studies The review first will consider any randomized controlled trials. In the absence of RCTs other research designs, such as non-randomized controlled trials, case-control and cohort studies and descriptive studies, will be considered for inclusion in the systematic review. Search Strategy The search strategy aims to find both published and unpublished studies in English language only from 1991 to current date. The search begins in the pivotal year following the introduction of new dyad interventions for older patients: (a) patient-caregiver dyad assessment and (b) assessment of caregiver learning needs 5,33,37. A three-step search strategy will be utilized in this review. An initial search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and expanded index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be hand searched for additional studies. The databases to be searched include: EMBASE, ERIC, the Cochrane Central Register of Controlled Trials (CENTRAL), PSYCH-Info, An additional grey literature search to identify unpublished studies/papers will include: Mednar, Virginia Henderson Library of Sigma Theta Tau, Robert Wood Johnson Institute, Literacy Educational Online (LEO), TRIPP, dissertations abstracts international. Investigators currently conducting studies on caregiver support will be contacted. Initial keywords to be used will be: (i) patients (MeSH), caregivers (MeSH), discharge planning (MeSH), patient discharge (MeSH), hospitals (MeSH); care transition (MeSH), patient care team(MeSH), interdisciplinary communication (MeSH), Patient - caregiver dyad (MeSH), patient-centered care (MeSH) A secondary Boolean query using smart search will include combinations of the following words and phrases: Patient-centered care, community acquired pneumonia, discharge education, carer, caregiver, readmission, unexpected readmissions, teaching instruction, learning needs, hospital readmissions, readmit, communication, coordination, unplanned readmissions, acute care discharge plan, caregiver assessment, re-hospitalization, learning needs, clinical discharge education, Meleis' transitions theory. Assessment of Methodological Quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer until consensus is reached. Data Collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Quantitative data will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of Interest There are no conflicts of interest.