Comprehensive Discharge Planning Research Articles

Embracing the changes imposed by COVID-19 to shape future stoma care service provision.

British Journal of NursingVol. 29, No. 22 CommentEmbracing the changes imposed by COVID-19 to shape future stoma care service provisionJuliette Fulham, Claire Lowther, Pip ChandlerJuliette Fulham(E-mail Address: [email protected])Senior Coloplast Nurse and Stoma Nurse Specialist, University College London Hospitals NHS Foundation TrustSearch for more papers by this author, Claire LowtherRegional Nurse Manager, Coloplast LtdSearch for more papers by this author, Pip ChandlerRegional Nurse Manager, Coloplast LtdSearch for more papers by this authorJuliette Fulham; Claire Lowther; Pip ChandlerPublished Online:16 Dec 2020https://doi.org/10.12968/bjon.2020.29.22.S10AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References McCall K, Keen J, Farrer K et al.. Perceptions of the use of a remote monitoring system in patients receiving palliative care at home. Int J Palliat Nurs. 2008;14(9):426-431. https://doi.org/10.12968/ijpn.2008.14.9.31121. Link, Google ScholarNHS England. Clinical guide for the management of remote consultations and remote working in secondary care during the coronavirus pandemic. 27 March 2020. https://tinyurl.com/y9n75p5m (accessed 30 November 2020) Google ScholarNHS UK. The NHS long term plan. 2019. https://www.longtermplan.nhs.uk (accessed 30 November 2020) Google ScholarPrinz A, Colwell J, Cross HH, Mantel J, Perkins J, Walker CA. A comprehensive discharge plan for a patient with a new stoma is needed to ensure the individual receives the necessary ostomy education prior to discharge. J Wound Ostomy Continence Nurs. 2015;42(1):79-82. https://doi.org/10.1097/WON.0000000000000094 Crossref, Medline, Google ScholarTheodoulou E, Tirimacco R, Dollman J, Duncan M, Coote E, Ferrar KE. Preferences and attitudes to mobile phone and Internet-based cardiac rehabilitation maintenance programs in rural Australia. Aust J Rural Health. 2019;27(2):179-180. https://doi.org/10.1111/ajr.12489 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited byAdaptation of a stoma care pathway and use of telephone clinics during the pandemic: patient experience surveyAnna Brewer, Vanessa Coleman12 January 2022 | British Journal of Nursing, Vol. 31, No. 1Implementation of a patient progress diary for stoma patients living with dementiaLorraine Coston, Judy Pullen10 December 2021 | British Journal of Nursing, Vol. 30, No. 22Stoma care services during the COVID-19 pandemicJennie Burch11 September 2021 | British Journal of Nursing, Vol. 30, No. 16 10 December 2020Volume 29Issue 22ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 16 December 2020 Published in print 10 December 2020 Information© MA Healthcare LimitedPDF download

Perception of Discharge Planning and Quality of Life among Patients with Coronary Artery Disease

Comprehensive discharge planning may enhance dimensions of the quality of life (QoL) in patients with coronary artery disease (CAD). Hence, the purpose of this study is to identify the correlation between perception of discharge planning and QoL among patients with CAD. A cross-sectional study was conducted using a self-administered questionnaire to 152 patients with CAD. The results from this study proved that majority of patients with CAD had a high level of QoL in the emotional domain (rho=-0.015, p=0.857) but low in the physical domain (rho=0.066, p=0.422) and social domain (rho=0.008, p=0.920). Keywords: discharge planning; quality of life; coronary artery disease. eISSN: 2398-4287© 2020. The Authors. Published for AMER ABRA cE-Bsby e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI:

Implementing a Nurse Discharge Navigator: Reducing 30-Day Readmissions for Heart Failure and Sepsis Populations.

The purpose of this quality improvement project was to evaluate the impact of a nurse discharge navigator on reducing 30-day readmissions for the heart failure and sepsis populations. The 238-bed community hospital in central Virginia is part of a health care system that encompasses 13 acute care facilities. The aim of this project was to identify, implement, and evaluate the transition of care of high-risk readmission patients from January 2019 to April 2019. Inclusion criteria included patients who were 55 years and older, English speaking, diagnosed with heart failure and/or sepsis, discharged to home with or without home health, and/or consults received from case management and social services. Forty-one potential participants were identified with 28 consented. Readmission data were collected pre- and postintervention. The pre-/postanalysis consisted of descriptive statistics, readmission rates, and cost avoidance. Out of the 28 participants, 7 participants were readmitted within 30 days. The heart failure readmission rates during the project implementation were as follows: January 24.05%, February 20%, March 19.75%, and April 11.11%. After the project completion the readmission rates were 22.97% for May and 26.03% for June, respectively. The potential cost avoidance with sustained gain from the project is $405,316.00. This project demonstrated that a discharge navigator had an effect on 30-day readmissions for high-risk heart failure and sepsis populations, as evident by a steady decline in overall heart failure readmission rate during project implementation. The sepsis population needs further research. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination, and education that is needed for these types of patient populations that have a great deal of medical complexity.

Patient Discharge Process Following Immune Effector Cell Therapy

Topic Significance & Study Purpose/Background/Rationale A Comprehensive Cancer Center (CCC) providing cellular immunotherapy treatments developed a standardized discharge process to ensure optimal continuity of care following immune effector cell (IEC) therapy. As utilization of IEC therapies increases, it is imperative to have an outlined comprehensive discharge plan to promote continuity of care, treatment-specific follow up, and ensure both patient and referring provider feel confident to assume follow-up care. Nurses are pivotal to this process development and implementation. Methods, Intervention, & Analysis Our center established a standardized discharge process which includes a summary conference where the attending physician and nurse coordinator outline the patient's treatment course, response to therapy and future treatment recommendations. Following the conference, the patient is seen in clinic as a final clinic visit to ensure patient understanding of discharge instructions. To ensure continuity, the nurse coordinator is present at all patient appointments. Education at these appointments include symptom management after discharge, medications, vaccination recommendations, and management of potential long-term side effects. A discharge packet with hardcopies of medical records and contact information is given to the patient and the referring provider. A phone call between the CCC attending provider and referring provider also occurs. Findings & Interpretation The comprehensive discharge process provides receiving providers with clinical and logistical information to support a successful transition plan for patients, and ensure the patients’ comprehensive understanding of their discharge summary and follow up plan. The development of an IEC Long Term Follow Up program is underway to ensure comprehensive follow up care for patients and to serve as a resource for referring providers following discharge. Discussion & Implications Nurses are on the forefront of caring for these novel IEC patients and play an integral role in the comprehensive, multidisciplinary discharge and follow up process. This includes reinforcing education regarding IEC therapy to patients and home facilities as well as providing clinical and logistical considerations essential for a successful transition home for patients.

Caring for Thai Traumatic Brain Injury Survivors in a Transitional Period: What Are the Barriers?

Objective: We aimed to explore the situations and experiences of Thai traumatic brain injury (TBI) caregivers and nurses who care for TBI patients during their transition from hospital to home. Material and Methods: A descriptive qualitative study was conducted in a tertiary hospital, in Songkhla province, Thailand. Five TBI family caregivers and nine nurses, who cared for TBI patients from admission to discharge, were selected for in-depth interviews and focus group discussions. Reviews of existing documents related to caring for someone during a transition period; such as: the caregiver’s booklet manual, nurse’s guideline, discharge education, and the service plan were also analyzed. Content analysis was used to explore caring for someone during a TBI situation, within the Thai context. Results: The findings revealed six main barriers in the current care system for TBI caregivers and nurses. These included: (1) inadequate discharge teaching information, (2) less time in caregiver’s supervision and support, (3) lack of a comprehensive discharge plan, (4) lack of coordination and communication in follow-up care, (5) less confidence in providing care without support at home, and (6) poor availability of resources and time for consultation. Conclusion: Caregivers require more information and supportive care in order to enhance their adaptation in taking care of TBI patients in the long term. Developing a tele-nursing based caregiver transitional support program among TBI caregivers is suggested.

Effectiveness of a Comprehensive Patient-centered Hospital Discharge Planning Intervention for Frail Older Adults

Effectiveness of a Comprehensive Patient-centered Hospital Discharge Planning Intervention for Frail Older Adults

Trajectories of clinical and parenting outcomes following admission to an inpatient mother-baby unit

BackgroundThis study aimed to examine trajectories of clinical and parenting outcomes following admission to a mother-baby unit (MBU), and to explore factors associated with these trajectories.MethodsWomen admitted to an MBU completed the Edinburgh Postnatal Depression Scale (EPDS), Depression, Anxiety and Stress Scale (DASS-21), Karitane Parenting Confidence Scale (KPCS) and Maternal Postnatal Attachment Scale (MPAS) at admission, discharge and 3 months following discharge. Questions assessing psychosocial risk and adult attachment style were also completed at admission, and information relating to service engagement in the time since discharge was collected at follow-up. Additional clinical and demographic information was extracted from the patient medical record.ResultsSeventy-five women participated in the study. Overall, significant improvements in mean scores on measures of anxiety and parenting confidence were maintained 3-months following discharge. However, the majority of women (93.3%) followed trajectories that were characterised by deterioration in self-reported mother-infant attachment following discharge. 62.9 and 34.6% of women followed trajectories of increased symptoms of depression and stress between discharge and follow-up, respectively. Across measures, the least optimal trajectories, or least optimal scores, at follow-up were associated with less secure maternal attachment style (associated with more anxiety symptoms, poorer parenting confidence and maternal-infant attachment), older maternal age (more depressive symptoms) and increased psychosocial risk (more anxiety symptoms).ConclusionsThe findings of this study highlight the clinical implications of anxious attachment style for the mental health and parenting outcomes of women admitted to an MBU and the importance of incorporating mother-infant therapy as part of an ongoing management plan. Comprehensive discharge planning and transitional care to help ensure women discharged from an MBU are best supported in the longer term is recommended.

30-Day Potentially Preventable Hospital Readmissions In Older Patients: Clinical Phenotype And Health Care Related Risk Factors.

PurposeEarly readmission rate has been regarded as an indicator of in-hospital and post-discharge quality of care. Evaluating the contributing factors is crucial to optimize the healthcare and target the intervention. In this study we evaluated the potential for preventing 30-day hospital readmission in a cohort of older patients and identified possible risk factors for readmission.Patients and methodsDiagnosis-Related Group (DRG) codes of patients consecutively hospitalized for acute disease in the Geriatrics Unit of the University Hospital of Pisa within a 1-year window were recorded. All the patients had received a comprehensive geriatric assessment. Crossing and elaboration of the DRG codes was performed by the Potentially Preventable Readmission Grouping software (3M™ Corporation). DRG codes were classified as stand-alone admissions (SA), index admissions (IA) and potentially preventable readmissions (PPR) within a time window of 30 days after discharge.ResultsIn total, 1263 SA and 171 IA were identified, with an overall PPR rate of 11.9%. Hospitalizations were significantly longer in IA and PPR than SA (p<0.05). The more frequent readmission causes were acute heart failure, pulmonary edema, sepsis, pneumonia and stroke. In acute heart failure a nonlinear U-shaped readmission trend (with nadir at 5 days of hospitalization) was observed while, in all the other DRG codes, the PPR rate increased with increasing length of hospitalization. Comprehensive geriatric assessment showed a significantly lower degree of disability and comorbidity in SA than IA patients. At stepwise regression analysis, a high degree of disability and comorbidity as well as the diagnosis of sepsis emerged as independent risk factors for PPR.ConclusionAddressing PPR is crucial, especially in older patients. The adequacy of treatment during hospitalization (especially in cases of sepsis) as well as the setting of a comprehensive discharge plan, accounting for comorbidity and disability of the patients, are essential to reduce PPR.

C-reactive protein kinetics post elective cranial surgery. A prospective observational study

Introduction: Post cranial surgery readmission, largely caused by surgical site infection (SSI), is a marker of patient-care quality requiring comprehensive discharge planning. Currently, discharge assessment is based on clinical recovery and basic laboratory tests, including C-reactive protein (CRP). Although CRP kinetics have been examined postoperatively in a handful of papers, the validity of CRP as a standalone test to predict SSI is yet to be explored.Methods: A prospective observational study was performed on adult patients undergoing elective cranial surgery over a 3-month period. Laboratory data; CRP, white cell count (WCC), neutrophil cell count (NCC), and clinical data were assessed pre and post-operatively and were evaluated as predictors for safe discharge. Readmission rates within 1 month were recorded.Results: In this study, 68 patients were included. About 8.6% were readmitted due to SSI. A postoperativepeak in CRP was seen on day 2 with a value of 57 in the non-readmitted group, and 115 in the readmitted group. CRP dropped gradually to normal levels by day 5 in the non-readmitted group. A secondary CRP rise at day 5 was noted in the readmitted group with a sensitivity, specificity, and negative predictive value of 71%, 90%, and 96%, respectively. Interestingly, our ROC analysis indicates that a CRP value of less than 65 predicts safe discharge with a sensitivity of 86%, specificity of 89% and negative predictive value of 98% of safe discharge (area under the curve, AUC: 0.782). No significant difference in other inflammatory markers was found between both groups.Conclusions: CRP increases postoperatively for 4–5 d which could be a physiological response to surgery, however, prolonged elevation or a secondary increase in CRP may indicate an ongoing infection. Our data validate the potential use of CRP levels to predict SSI. A multicentre study is warranted to investigate the role of CRP in predicting SSI.

Predictors of 30-day rehospitalization in a sample of hospitalized patients with Bipolar I disorder

The transition from psychiatric hospitalization to home is marked by high clinical vulnerability, characterized by risk of symptom rebound, exposure to preexisting stressors, and challenges with outpatient treatment linkage. Rates of rehospitalization during this post-discharge period, particularly for those with bipolar disorder, are reported to be high. This study evaluated demographic and clinical predictors of early rehospitalization (within 30 days) in a sample of hospitalized adults with Bipolar I disorder (BD-I). A chart review was conducted for 215 patients with BD-I admitted to an academically-affiliated psychiatric hospital within one calendar year. A computer algorithm was used to extract relevant demographic, clinical, and treatment information. Univariate and multivariate logistic regression models were used to examine predictors of early rehospitalization. Overall, 12% of participants were readmitted within 30 days of discharge. Controlling for other clinical and demographic variables, patient functioning and pre-admission psychiatric polypharmacy, but not comorbid psychiatric diagnoses, predicted early readmission in patients with BD-I. Findings highlight the relative importance of considering low psychosocial functioning, and medication regimens containing multiple psychiatric medications, during hospitalizations. These features may indicate a subset of patients with BD-I who require more comprehensive discharge planning and support to transition to the community following a psychiatric hospitalization.

Family Involvement in Psychiatric Hospitalizations: Associations With Discharge Planning and Prompt Follow-Up Care.

Involving family in the care of inpatients with serious mental illness is known to be beneficial. This study examined frequencies of involvement by family in the care and discharge planning for 179 psychiatric inpatients. Involvement by family in care and discharge planning was assessed from randomly selected medical records of inpatients with Medicaid and severe mental illness at two New York hospitals from 2012 to 2013. "Family" also included anyone close to the patient who provided support. Medicaid claims were reviewed for patient demographic and clinical characteristics and for postdischarge outpatient attendance data. Multiple regression models were used to test whether involvement by family was associated with comprehensive discharge planning (contacting outpatient providers, scheduling follow-up appointments, and forwarding a discharge summary to a provider) and initiation of outpatient treatment. Inpatient staff contacted a family member for 134 (75%) patients. Sixty-seven (37%) patients received comprehensive discharge planning, and 96 (53%) and 139 (78%) attended an outpatient appointment within 7 and 30 days of discharge, respectively. Inpatient staff contacting family, communicating about the patient's health and/or mental health, and communicating about the discharge plan were significantly associated with entry into follow-up care by 7 and 30 days postdischarge. Family phone calls and/or visits with patients, attendance at family therapy sessions, and communication with inpatient staff about services available to families were significantly associated with patients receiving comprehensive discharge planning. When analyses controlled for demographic and clinical factors, having any involvement between family members and inpatient staff was significantly associated with patients' attending an outpatient appointment by 7 days (odds ratio [OR]=2.79, 95% confidence interval [CI]=1.28-6.08) or 30 days (OR=3.07, 95% CI=1.29-7.32) after discharge. The association of family involvement with comprehensive discharge planning and prompt entry into outpatient care underscores the importance of family contact and communication with staff during inpatient hospitalizations.

Antiretroviral Prescription Pick-up and Physician Follow-up After Hospital Discharge Among Medically Complex People With HIV

In this study, only 22 of 206 (10.7%) socially marginalized individuals living with HIV and multiple comorbid conditions filled a prescription for antiretroviral therapy within 7 days of discharge from an HIV specialty hospital, despite comprehensive discharge planning. Additional interventions facilitating postdischarge continuity of care are required for this population.

What older adults want from their health care providers

Changing demographic trends and population needs have increased demand for chronic complex care and contributed to rising health care costs. The study sought to identify unmet health care needs of older adults and opportunities for service improvement in a high need suburban neighborhood of a prairie province. The insights provided by older adults informed the service design for a new model of integrated care in community settings. Narrative inquiry methodology was used to understand care experiences through stories. Stories of older adults’ health care journeys were elicited with semi-structured interviews. A paradigmatic approach to analysis was applied with holistic coding, mapping of story elements followed by comparison and theming across participants’ stories. Older adults perceived that relationship and informational continuity fostered effective communication and supported coordination of care. Timely access to care was valued and flexibility in types of medical encounters was suggested as an option to improve provider responsiveness. Access to information about community resources was limited and older adults required support with navigation. Structural (e.g. availability of services and transportation), financial and personal barriers exist for older adults to access and use community health services. Health care transitions were inadequately supported by comprehensive discharge planning, timely communication and follow up post discharge. New models of care need to embrace person-centred and goal directed approaches to the delivery of care to improve patient experience. Older adults offer valuable perspectives as community partners and co-designers of systems change in efforts to re-engineer health services.

Influence of interactional structure on patient’s participation during interprofessional discharge planning meetings in rehabilitation centers

ABSTRACT Interprofessional practice has become increasingly important. In addition, patients are expected to participate more actively in health-care decisions. While comprehensive discharge planning has been shown to be effective, it is unclear how interactional structure influences patients’ participation during discharge planning meetings. The aims of this qualitative study were to examine the interactional structure of interprofessional meetings in two rehabilitation clinics and to identify patients’ types of communicative involvement (patient participation) during discharge planning meetings. Using an ethnomethodological approach and Conversation Analysis, 121 interprofessional meetings were video-recorded (19 hours of recordings). Twenty-five patients (30– 87 years) with neurological or musculoskeletal disorders and their teams were included. The findings revealed two types of meetings aimed at either (a) exchanging information with team members and patient (“information exchange meeting”) or (b) negotiating care plans with patients and the team. “Negotiation meetings” were often led by allied health professionals or nurses and were characterized by active patient participation. Those meetings offered patients an opportunity to give additional information rather than only ask questions. The discussion includes reflections on how interactional analysis can help understand the social organization of meetings and how patient participation can be enhanced in this context and concludes with practice implications.

A randomized controlled study of intervention to improve continuity care engagement among HIV-infected persons after release from jails

ABSTRACTShort-term stay, multiple jail admissions and social and financial difficulties are significant obstacles for continuity care engagement (CCE) after release among HIV-infected jail detainees. However, data existing on interventions or strategies to increase post-release CCE among this population are limited. We conducted a randomized controlled study among HIV-infected detainees at Cook County Jail during 2011–2014. The intervention group received telephone contact within 2–4 days of release by a continuity clinic coordinator, who scheduled and informed the ex-detainees of their appointment date within 6 weeks post-release plus standard of care, while the control group received standard of care. The standard of care included comprehensive discharge planning, offering substance abuse treatment and provision of information on how to self-schedule an appointment with the chosen clinics. Of the 166 detainees enrolled, 56 were excluded due to being sent to prison or re-incarcerated within 6 weeks. The final cohort included 55 detainees in each of the groups. The rate of CCE within 6 weeks after release was significantly higher in the intervention group compared to the control group (58% vs. 33%; P = .007). In multivariable logistic regression analysis, being in the control group was the only factor associated with no CCE within 6 weeks (adjusted odds ratio 2.66; 95% confidence interval 1.18–6.00; P = .02). The study findings suggest that the simple telephone contact intervention significantly improved CCE among HIV-infected jail detainees.

OP40 Effect Of Advanced Nursing Practice On Hospital Use For The Elderly

Introduction:Within the local context in Montréal, the elderly population makes up more than 50% of patient hours in emergency department. To meet ministerial targets for length of stay, our health technology assessment unit was requested to conduct an umbrella review to evaluate interventions aimed at reducing health care services use for this population. Within that context, our unit was asked to further evaluate the efficacy of advance practice nurse (APN)-led interventions. The objective of this rapid response was to summarize the scientific literature for APN-led interventions on hospital services use.Methods:An umbrella review using the PRISMA statement was conducted to review the scientific literature. Systematic searches were conducted in five databases, along with a grey literature search. Two reviewers performed the study selection, quality assessment using the ROBIS, and data extraction. The primary studies within the selected systematic reviews were extracted by two reviewers and a meta-analysis was conducted to analyze the efficacy of APN-involved in discharge planning and transitional care.Results:From the twenty-seven systematic reviews identified in the literature search, four reported data on APN-led interventions. In all, sixteen primary studies were included in the four systematic reviews. While most studies focused on transitional care, there was heterogeneity in the components of the interventions implemented. At six months post-discharge, a reduction of forty-one percent in relative risk of readmission was observed with APN-led discharge planning and transitional care with patient education, follow-up and services coordination. Studies with fewer components reported less significant results than studies with comprehensive discharge planning and transitional care. The few APN-led primary care studies identified in the systematic reviews reported inconsistent results.Conclusions:APN-led comprehensive discharge planning and transitional care can reduce hospital readmission rate. Several components were identified and should be considered in the discharge planning and transitional care.

The Framework of NICU-discharge Plan System for Preterm Infants in Iran: Duties, Components and Capabilities.

Introduction:The development of comprehensive discharge plan system Not only, will facilitate the discharge process, increase staff and parent satisfaction, improve the care of preterm infants, also reduce the human error.Aim:to determine duties, components and capabilities of NICU discharge plan system as a multidimensional tool for facilitating the complex process of transition preterm infants to the home and support parents for post-discharge care.Method:The descriptive and qualitative study conducted in 2017. Firstly by literature review, components of framework were determined in 38 statements under 3 major themes: duties, components, and capabilities and then related questionnaire was provided. Cronbach’s alpha test was used to assess the reliability of the questionnaire. The result was more than 0.82 for all statements of questionnaire. The validity of the instrument was determined based on concepts in the valid scientific texts and comments of experts. The analysis was performed using SPSS software.Result:In overall, 29 experts participated in the consensus process. In the duties section, all of the statements reach more than 50% consensus. Among statements of the components and capabilities consensus was achieved in 12 out of 17, 12 out of 16 statements respectively.Conclusion:according to survey, checkout infant readiness determined as the main duty of the system. Alarm message for special examination before discharge and parent readiness checklist considered as the most important components. The ability to send alarm message, register and log in system were the key capabilities of the discharge system.

The Quality of Discharge Care Planning in Acute Stroke Care: Influencing Factors and Association with Postdischarge Outcomes

Comprehensive discharge planning is important for successful transitions from hospital to home after stroke. The aim of this study was to describe the quality of discharge planning received by patients discharged home from acute care, identify factors associated with a positive discharge experience, and assess the influence of discharge quality on outcomes. Patients discharged to the community and registered in the Australian Stroke Clinical Registry in 2014 were invited to participate. Patient-perceived discharge quality was evaluated using the Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations, Empowerment, Directed to appropriate services questionnaire (recall at 3-9 months). Factors associated with higher discharge quality scores were identified and associations between quality scores of more than 80% and outcomes were investigated using multivariable, multilevel regression analyses. There were 200 of 434 eligible registrants who responded; responders and nonresponders were similar with respect to age, sex, and type of stroke. The average overall quality score was 73% (standard deviation: 21). However, only 18% received all aspects of discharge care planning. Quality scores of more than 80% were independently associated with receiving hospital specific information (odds ratio: 5.7, 95% confidence interval [CI]: 2.7, 12.4), and referral to a local support group (odds ratio: 2.5, 95% CI: 1.1, 5.9). Discharge quality scores of more than 80% were associated with higher European Quality of Life-5 Dimensions EQ-5D scores (coefficient: .1, 95% CI: .04, .2) and a reduction in the rate of unmet needs reported at 3-9 months postdischarge (incidence rate ratio: .5, 95% CI: .3, .7). We provide new information on the quality of discharge planning from acute care after stroke. Aspects of discharge planning that correlate with quality of care may reduce unmet needs and improve quality of life outcomes.

Travel Time Influences Readmission Risk: Geospatial Mapping of Surgical Readmissions.

The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients' residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01-1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.

Outpatient Management of Neonatal Abstinence Syndrome: A Quality Improvement Project

An increasing number of infants are diagnosed with neonatal abstinence syndrome (NAS). The study's primary objectives were to describe an academic medical center's level IV neonatal ICU's (NICU's) comprehensive outpatient NAS management effort, measure guideline compliance, and assess its safety. Secondary objectives were to describe the duration and cumulative methadone exposure, and to improve parent and provider knowledge of NAS. The study included 22 infants having a gestational age of 35-41 weeks, diagnosed with NAS, and discharged for outpatient methadone management. Discharges spanned 10 months and included 3 improvement periods. The outpatient program includes comprehensive discharge planning, a focused electronic health record (EHR) template, management guidelines, and parent and provider education. Providers complied with using the outpatient management guideline and EHR template, and assessed weight, NAS symptoms, and methadone dose during appointments. Two infants required NAS-related hospital readmission in the study period. From improvement period 1 to period 3 there was no difference in total outpatient days on methadone (58, 53, 74 days, respectively) or cumulative methadone dose (2.7, 2.6, 3.1mg/kg, respectively). A downward trend pattern in cumulative methadone exposure was noted in improvement period 2. Pre- and postimplementation surveys revealed that after implementation, parents had better understanding of NAS before delivery (71% vs. 100%, p = 0.009), while providers had increased comfort with outpatient management (24% vs. 67%, p < 0.001) and educating parents (48% vs. 82%, p = 0.001). This preliminary study suggests that outpatient NAS management can be safe when a comprehensive management program is implemented and can result in provider compliance with the program.