Discharge Intervention Research Articles

Readmission of High-Risk Discharged Patients at a Tertiary Hospital in Korea.

This study aims to investigate the readmission rates of major disease groups as stated by the Centers for Medicare and Medicaid Services and to identify risk factors related to readmission in Korea. We studied 2,973 patients discharged from a 2,200-bed tertiary referral hospital in South Korea, from April 1, 2016, to March 31, 2017. Using electronic medical records, we calculated the 30-day readmission rates of seven diseases: acute myocardial infarction, chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, stroke, coronary artery bypass graft (CABG), and total hip arthroplasty/total knee arthroplasty. We used Cox proportional hazards regression analysis to identify risk factors affecting readmission in this retrospective, observational study. For 2,973 consecutively discharged patients, the 30-day unplanned readmission rate was 10.3%. The readmission rate of HF (19.0%) was the highest, followed by pneumonia (13.7%), CABG (12.0%), and COPD (10.5%). Factors associated with readmission were polypharmacy (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.60-2.64), hospitalization history in the previous 6 months (HR: 1.81; 95% CI: 1.41-2.32), and comorbidity (HR: 1.16; 95% CI: 1.11-1.23). Therefore, the discharge intervention program for high-risk discharge patients with polypharmacy, admission history, and comorbidity should include medication reconciliation.

Effects of health education under the concept of health quotient on self-management ability and medication compliance among ulcerative colitis patients

Objective To explore the effects of health education under the concept of health quotient on self-management ability and medication compliance among ulcerative colitis patients. Methods From December 2015 to December 2017, we selected 140 ulcerative colitis patients at Nanyang City Center Hospital of the Affiliated Hospital of Zhengzhou University as subjects by convenience sampling. All of the patients were divided into observation group and control group with the method of random number table, 70 cases in each group. Control group adopted routine health education, while observation group carried out health education under the concept of health quotient which implemented health education using five dimensions of health quotient concept as start points. The intervention effects of patients of two groups, self-management ability and medication compliance, were compared with the Adult Health Self-Management Skill Rating Scale (AHSMSRS) and Morisky Medication Adherence Scale before (on admission) and after (reexamining three months after discharge) intervention. Results Before intervention, there were no statistical differences in the dimension scores of AHSMSRS of patients between two groups (P>0.05) . After intervention, the scores of AHSMSRS both groups all increased compared with those before intervention; the scores of diet management, sport management, responses to the diseases, resource usage, self-efficacy and environment self-management and the total score of AHSMSRS in observation group after intervention were higher than those in control group with statistical differences (P<0.05) . After intervention, the fine rate of medication compliance of observation group was 95.71% statistically higher than that (85.71%) of control group (P<0.05) . Conclusions Health education under the concept of health quotient can improve self-management ability and medication compliance among ulcerative colitis patients which is worthy of being spread in clinical application. Key words: Colitis, ulcerative; Medication adherence; Health education; Concept of health quotient; Self-management ability

Impact of hospitals’ Referral Region racial and ethnic diversity on 30-day readmission rates of older adults

ABSTRACTBackground: The Hospital Readmissions Reduction Program (HRRP) began decreasing Medicare payments to hospitals reporting high readmission rates for individuals over 65. Thus, financially incentivizing hospitals to improve quality performance on preventable readmissions. Well-established research indicates that minorities are more frequently readmitted to hospitals, but it is unknown if community diversity is associated with 30-day readmission rates.Objectives: To investigate the association between racial/ethnic diversity and hospitals’ 30-day readmission rates.Methods: We linked the 2017 HRRP, American Hospital Association (AHA) database, Area Health Resource File, US Census Bureau Current Population Survey, and the Dartmouth Atlas HRR dataset to examine 30-day readmission rate for heart failure (HF), pneumonia (PN), acute myocardial infarction (AMI), and hip replacement (HR) surgery of 4,299 hospitals across 306 HRRs.Results: Our findings indicate a statistically significant negative relationship between diversity and 30-day readmission rates for HF, PN, AMI, and HR with a hospital referral region (HRR). Thus, hospitals located in HRRs with diverse populations are more likely to have higher 30-day readmission rates for all conditions under Medicare’s HRRPConclusion: Better discharge follow-up, interventions, and use of support staff aimed at meeting needs associated with differences in communities and cultures are likely to prove more fruitful than traditional one-size fits all approaches to care.

Effects of an Intensive Discharge Intervention on Medication Adherence, Glycemic Control, and Readmission Rates in Patients With Type 2 Diabetes.

Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.

Effectiveness of a post-emergency department discharge multidisciplinary bundle in reducing acute hospital admissions for the elderly.

We evaluated the effectiveness of the Subacute Ambulatory care for the Functionally challenged and Elderly (SAFE) programme, a post-emergency department (ED) discharge intervention for elderly and functionally challenged patients, in reducing acute hospital admissions. This study was a 32-month retrospective quasi-experimental study comparing patients with at least one of six diagnostic classifications who underwent SAFE intervention with those who were eligible but declined and received usual ED care (control). The primary outcomes were rates of first acute hospital admission at 30 and 60 days post-ED discharge. Secondary outcomes were 20-day withdrawal rate and 60-day mortality. The difference in primary outcome between the two groups was compared using a Cox proportional hazards model. We reported adjusted hazard ratios (HRs) with their 95% confidence intervals (CIs) adjusting for predefined factors of age, sex, triage risk assessment tool scores and baseline ED utilization and acute hospital admission rates in the past year. There were 438 and 209 patients in the intervention and control groups, respectively. The intervention group had reduced risk of first acute hospital admission at 30 days (10 vs. 27%, HR=0.34, 95% CI: 0.22-0.52) and 60 days (18 vs. 33%, HR=0.48, 95% CI: 0.34-0.69) compared with the control. The 20-day withdrawal rate was 3.2%. Both groups did not differ in 60-day mortality rates. The SAFE programme was effective in reducing first acute hospital admissions in selected elderly and functionally challenged patients after ED discharge at 30 and 60 days compared with usual ED discharge care.

BMT Program Re-Admissions – the Need to Monitor and Classify Risk Factors to Identify Possible Interventions to Prevent Avoidable Re-Admissions and Reduce Morbidity Following Allogeneic Stem Cell Transplantation (allo-SCT).

Objective and Background Hospital re-admissions contribute significantly to increased healthcare costs and have been a focus of various quality improvement initiatives at Baylor University Medical Center (BUMC). Re-admissions metrics are available at the hospital level not at the BMT program level. The goal of this study is to create a consistent methodology to identify BMT re-admissions, analyze the cause of the re-admissions on an ongoing basis to identify possible interventions to reduce preventable re-admissions and reduce morbidity. Method Patients that underwent an allogeneic BMT at Baylor University Medical Center (Dallas, TX) (BUMC) between January 2013 through December 2017 were included in this retrospective study. The BMT patients were identified from the hospital electronic medical record (EMR) system based on identifiers used in the internal transplant data management system and the Diagnosis Related Group (DRG) code assigned to the index transplant event. Any discrepancies identified in the data obtained from the EMR were resolved manually. Admissions in other services such as ICU and Oncology units at BUMC were included in the data. Including re-admissions to outside hospitals remain a challenge. Descriptive analysis was performed on the cohort of readmitted transplant patients. The frequencies of reasons, DRG codes, and International Classification of Diseases (ICD)-10 codes for readmission in the first year post-transplant were calculated. The patients were stratified into 30-, 60-, 90-, 180- and 365-day time points based on the number of days between the dates of transplant and readmission. Data clean-up and chart review was needed to clarify the data categorized by DRG or ICD-10 descriptions. Results More than 50% of the re-admissions among the BMT patients occur within the first 30 days post-transplant. The most frequent reason for readmission was infection or a fever (with or without positive culture). The cause for the re-admissions vary at different time points. Re-admissions at the 30 – 60 day point were more frequently related to graft-versus-host disease (GVHD), gastrointestinal complications and other reasons such organ failure. As the interval between transplant and readmission approaches 90 days or greater, the reasons are more evenly distributed. Conclusion A consistent review of BMT readmission data might be beneficial in identifying and reducing potentially preventable readmission causes and reducing morbidity. A more structured and intense follow-up process in the first 60 days post-transplant may be the most effective use of program resources. Patient education may benefit from being structured around different time point post-transplant. A review with the program Medical Director suggests a margin for discharge interventions such as education and patient expectation management at different time points post-transplant.

Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital

The downward trend in readmissions has recently slowed. New enhancements to hospital readmission reduction efforts are needed. Structured assessment of patient readiness for discharge has been recommended as an addition to discharge preparation standards of care to assist with tailoring of risk-mitigating actions. To determine the effect of unit-based implementation of readiness evaluation and discharge intervention protocols on readmissions and emergency department or observation visits. The Readiness Evaluation and Discharge Interventions (READI) cluster randomized clinical trial conducted in medical-surgical units of 33 Magnet hospitals between September 15, 2014, and March 31, 2017, included all adult (aged ≥18 years) patients discharged to home. Baseline and risk-adjusted intent-to-treat analyses used difference-in-differences multilevel logistic regression models with controls for patient characteristics. Of 2 adult medical-surgical nursing units from each hospital, 1 was randomized to the intervention and 1 to usual care conditions. Using the 8-item Readiness for Hospital Discharge Scale, the 33 intervention units implemented a sequence of protocols with increasing numbers of components: READI1, in which nurses assessed patients to inform discharge preparation; READI2, which added patient self-assessment; and READI3, which added an instruction to act on a specified Readiness for Hospital Discharge Scale cutoff score indicative of low readiness. Thirty-day return to hospital (readmission or emergency department and observation visits). Intervention units above median baseline readmission rate (>11.3%) were categorized as high-readmission units. Among the 33 intervention units, 17 were low-readmission units and 16 were high-readmission units. The sample included 144 868 patient discharges (mean [SD] age, 59.6 [17.5] years; 51% female; 74 605 in the intervention group and 70 263 in the control group); 17 667 (12.2%) were readmitted and 12 732 (8.8%) had an emergency department visit or observation stay. None of the READI protocols reduced the primary outcome of return to hospital in intent-to-treat analysis of the full sample. In exploratory subgroup analysis, when patient self-assessments were combined with readiness assessment by nurses (READI2), readmissions were reduced by 1.79 percentage points (95% CI, -3.20 to -0.40 percentage points; P = .009) on high-readmission units. With nurse assessment alone and on low-readmission units, results were mixed. Implemented in a broad range of hospitals and patients, the READI interventions were not effective in reducing return to hospital. However, adding a structured discharge readiness assessment that incorporates the patient's own perspective to usual discharge care practices holds promise for mitigating high rates of return to the hospital following discharge. ClinicalTrials.gov Identifier: NCT01873118.

Polymorphism of TNF gene in acute coronary syndrome patients: data from the registries ORACLE I and ORACLE II

Aim . To analyze possible association of the risk of adverse outcomes development in patients post acute coronary episode (ACS), with the polymorphism of gene TNF. Material and methods . To the study, patients included, that were under observation in 2 registry studies ORACLE I and II (Exacerbation of coronary heart disease: logic-probability ways of course prediction and treatment optimization). In overall, 2012 ACS patients assessed. Mean age 64,7±12,69 y.o. There were 1205 males (59,8%) and 807 females (40,2%). 741 patients (36,8%) included with ST elevation ACS, 1271 (63,2%) — with non-ST elevation ACS. Follow-up started at the 10th day from clinical stabilization. Clinical outcomes were gathered based on phone calls with the patients and their relatives, as during the outpatient office visits. Assessment of polymorphisms of gene TNF done with PCR. Results . In the assessed group, the frequency of alleles and gene TNF genotypes were measured: 18 patients carried genotype АА (0,9%), 561 patients — AG (279%), 1433 — GG (71,2%). In those with the allele А gene TNF, more commonly the episodes of SCD were noted (9,8% comparing to 6,6% of GG carriers, p&lt;0,001); rate of non-cardiac death did not differ significantly (3,5% and 3,1%, respectively). There were no significant differences in the rate of fatal and non-fatal strokes, number of non-complicated cases of peripheral atherosclerosis. In the group of patients with allele A, there were more common the repeated ACS episodes (21,4% vs 12,8% in GG carriers, p&lt;0,001). The rate of repeated after discharge interventions did not differ significantly. Independent factors for any adverse outcome (death, ACS, stroke, complicated atherosclerosis, repeated coronary interventions) were myocardial infarction (OR 1,235 (1,041-1,464)) and heart failure (OR 1,22 (1,02-1,44)) in anamnesis, decreased GFR (OR 1,04 (0,87-1,43)) and carriage of АА and AG gene TNF (OR 1,35 (1,14-1,60)). Conclusion . Carriage of the rare A allele of polymorphic marker G(-308)A gene TNF is associated with more common development of adverse outcomes in patients after exacerbation of CHD.

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis.

Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. We searched 7 bibliographic databases and 5 pediatric journals. Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded. Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. Variability limited findings and reduced generalizability. In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

Status and influencing factors of readiness for hospital discharge among chronic heart failure patients

Objective To understand the status of readiness for hospital discharge among chronic heart failure (CHF) patients and to explore its influencing factors, so as to provide an objective evidence for formulating individualized intervention. Methods We selected 398 CHF patients ready for discharge of cardiology medicine in the Second Affiliated Hospital of Harbin Medical University from May 2016 to August 2017 by convenience sampling. The general information questionnaire and Readiness for Hospital Discharge Scale (RHDS) were used to assessed patients' readiness for hospital discharge and its influencing factors. Results The total score of RHDS and the scores of three dimensions in adaptability, personal status and expected support were (98.01±15.20) , (40.26±5.12) , (23.78±4.05) and (33.86±6.03) respectively. Single factor analysis showed that the influencing factors of readiness for hospital discharge of CHF patients were living style, educational background, duration of disease and heart function (t=-6.92, 10.55, 19.00, 29.47; P<0.05) . Conclusions CHF patients are with the good readiness for hospital discharge. Health care providers should formulate the individualized scheme of discharge instructions and intervention based on patients' specific circumstance so as to ensure patients' safety and life quality after discharge. Key words: Heart failure; Chronic diseases; Readiness for hospital discharge; Influencing factors

A systematic review of the effectiveness of clinical nurse specialist interventions in patients with chronic obstructive pulmonary disease (COPD)

Abstract Objective This review aimed to examine the effectiveness of clinical nurse specialist (CNS) interventions in patients with chronic obstructive pulmonary disease (COPD). COPD significantly affects people’s health worldwide. With the development in nursing, CNSs are playing increasingly important roles in different departments. However, the studies on the effectiveness of CNSs in COPD are not as well organized as the studies on the effectiveness of CNSs in bronchiectasis and asthma. Therefore, this review aims to find some updated evidence on the CNS interventions for patients with COPD and on whether these interventions are effective. Methods A narrative analysis of the data was performed for the eligible studies. Four databases were chosen: CINAHL, MEDLINE, British Nursing Index, and Cochrane Library. Other websites such as the National Institute for Health and Clinical Excellence, National Health Service Evidence, Association of Respiratory Nurse Specialists, and National Association of Clinical Nurse Specialist were searched as well. Two reviewers performed study identification independently, and all the retrieved articles were stored using the EndNote X7 software. The risk of bias in the included studies was assessed using the Cochrane Collaboration’s risk of bias tool. Results A total of nine studies were included in this review. There were five current interventions by CNSs for patients with COPD. These interventions were home nursing support, CNS’s supported discharge, multidisciplinary cooperation programs, nurse-led care programs, and self-care management education. The effectiveness of these five interventions was evaluated individually. There is low- to moderate-quality evidence indicating that home nursing support interventions may have a positive effect on mortality and quality of life. No significant difference in quality of life has been found between the CNS-supported discharge intervention and the usual service. The multidisciplinary cooperation program probably had a positive effect on quality of life in patients with COPD. Both nurse-led care and self-care management education intervention had a positive effect on mortality of patients with COPD. Conclusions The findings of this review provide updated evidence on the effectiveness of CNS interventions for patients with COPD. Although nine trials were included and five types of interventions were identified, there is still lack of high-quality evidence.

Early discharge in acute mental health: A rapid literature review.

Long psychiatric hospital stays are unpopular with services users, harmful, and costly. Economic pressures alongside a drive for recovery-orientated care in the least restrictive contexts have led to increasing pressure to discharge people from hospital early. Hospital discharge is, however, complex, stressful, and risky for service users and families. This rapid literature review aimed to assess what is known about early discharge in acute mental health. Searches were conducted in nine bibliographic databases, reference lists, and targeted grey literature sources. Fourteen included papers focused on early discharge in mental health, a population over 18years with a mental health condition, and reported outcomes on therapeutic care or service delivery. Quality appraisal was undertaken using The Mixed Method Appraisal Tool. The meta-summary of the literature found that early discharge was neither provided to all inpatients nor limited to the Crisis Resolution and Home Treatment (CRHT) service model internationally. Early discharge interventions required collaborative working and discharge planning. It was not associated with unplanned readmissions and had a small effect on length of stay. Most studies reported service outcomes, whereas health outcomes were underreported. Professionals and service users were positive about early discharge and service users asked for peer support. Carers preferred hospital or day hospital care suggesting their need for respite. Limitations in the scope, detail, and quality of the evidence about early discharge leave an unclear picture of the components of early discharge as an intervention, its effectiveness, cost-effectiveness, or outcomes.

CATCH-22: a manual bladder washout protocol to improve care for clot retention.

To review current practices in manual bladder washouts (MBW) for haematuria with clot retention, comparing those conducted by a urology unit to other inpatient services. Secondly, to describe a standardised protocol for MBWs. Prospective data were collected for patients treated for clot retention, from initial management by referral units through to implementation of a standardised MBW by the urology service. Outcomes measured included re-catheterisation, MBW volumes, clot evacuated and time to discharge or subsequent intervention. Initial catheters inserted by referral teams were sized 16Fr-20Fr, all except one requiring upsizing. Mean washout volumes of 145ml (SD 125) and 5392ml (SD 847) were used by referring units and the urology service, respectively. Mean volume of clot evacuated by the standardised MBW was 617ml (SD 313). Continuous bladder irrigation (CBI) was commenced in 16 patients (66%) prior to referral to urology. Median time to discharge was 48h. Initial catheter insertion is of inadequate size, as is the volume of washout performed. Referring services fail to clear adequate amounts of clot with washouts posing potential risks to patients. The standard management of clot retention should involve the use of at least a 22F catheter, implement best practice infection control and adopt the last Clot + 1L rule with catheter manipulation. The key points of our recommended MBW are summarised with the acronym CATCH-22. This protocol can guide initial management of clot retention and be used as an educational tool.

External validation of the 80+ score and comparison with three clinical scores identifying patients at least 75 years old at risk of unplanned readmission within 30 days after discharge.

A potentially avoidable readmission is an unplanned readmission occurring within 30 days of discharge. As 20% of hospitalised elderly patients are rehospitalised as an unplanned readmission, it is necessary to identify with a clinical score those patients who are at risk of readmission and need discharge interventions as a priority. The main objective of this study was to externally validate and compare the 80+ score with the three other scores predicting the risk of unplanned readmission. We conducted a retrospective case-control study using a clinical data warehouse. The study included patients hospitalised between 1 September 2014 and 31 October 2015 in an 800-bed university hospital. We included patients aged 75 and over. Cases were readmitted at the emergency department within 30 days after the index discharge. Controls were not readmitted as an emergency within 30 days. Four clinical scores (80+ score, LACE index, HOSPITAL score, TRST) were externally validated. Discrimination of the scores was assessed by calculating the area under the receiver operating characteristic curves (AUC). Calibration was assessed with a Hosmer-Lemeshow χ2 test. We included 438 patients. For discrimination, the 80+ score, the LACE index, the HOSPITAL score and the TRST had AUCs of 0.506 (95% confidence interval [CI] 0.413-0.546), 0.534 (95% CI 0.459-0.591, 0.517 (95% CI 0.466-0.598) and 0.589 (95% CI 0.524-0.654), respectively. The Hosmer-Lemeshow χ2 tests had p-values of 0.44, 0.43, 0.11 and 0.49, respectively. In our study, the 80+ score was externally validated and showed less favourable discrimination than the three other scores in this population.

The impact of mental health disorders on 30-day readmission after bariatric surgery

BackgroundMental health disorders are common among bariatric surgery patients. Mental health disorders, particularly depression, have been associated with poorer surgical outcomes, indicating the bariatric surgery patient population warrants special clinical attention. ObjectiveOur study sought to examine the effect of diagnosed mental health disorders on 30-day readmission for those undergoing bariatric surgery in hospitals across Pennsylvania from 2011 to 2014. MethodsWe used Pennsylvania Healthcare Cost Containment Council data to perform this analysis. Inclusion criteria encompassed patients aged>18 years who underwent bariatric surgery at any hospital or freestanding surgical facility in Pennsylvania between 2011 and 2014. Mental health disorders were identified using predetermined International Classification of Disease, Ninth Revision codes. Logistic regression was used to model the risk of 30-day readmission and estimate the effect of mental health disorders on 30-day readmission. ResultsOf the 19,259 patients who underwent bariatric surgery, 40.3% had a diagnosed mental health disorder; 6.51% of all patients were readmitted within 30 days. Patients with a diagnosed mental health disorder had 34% greater odds of readmission (odds ratio = 1.34, 95% confidence interval: 1.19–1.51) relative to patients with no diagnosed mental health disorder. Patients with major depressive disorder/bipolar disorder had 46% greater odds of being readmitted compared with patients with no major depressive disorder/bipolar disorder diagnosis. ConclusionStudy findings imply the need for risk assessment of patients before postoperative discharge. Given that patients with mental health diagnoses are at increased risk of 30-day readmission after bariatric surgery, they may benefit from additional discharge interventions designed to attenuate potential readmissions.

Discharge Interventions and Modifiable Risk Factors for Preventing Hospital Readmissions in Children with Medical Complexity.

Concerns about the costs and quality of hospital care have led to increased interest in hospital readmissions in children. Children with medical complexity account for high proportions of inpatient utilization and have a higher risk of hospital readmission. To identify studies of discharge interventions to prevent hospital readmissions in children with medical complexity. We conducted a search to identify studies of discharge interventions. Included studies 1) described an intervention or modifiable risk factor around the time of hospital discharge 2) included pediatric patients with chronic illness and/or medical complexity and 3) reported subsequent hospital utilization. We identified ten studies testing the following interventions: multi-faceted discharge bundle (including medication review, discharge education, and follow-up appointments) (s=1), post-discharge follow-up clinic visits (s=3), post-discharge phone calls (s=2), intensive follow-up interventions for very low birth weight infants (s=2), and education interventions in children hospitalized with asthma (s=2). Four studies reported reductions in readmissions. The discharge bundle correlated with an 11.1% decrease in 30-day readmission (9.9% vs. 8.8%, p&lt;0.05). All three studies of post discharge follow-up clinic visits reported a decrease in 30-day readmission risk among children with follow-up scheduled within 30 days, though one study also reported that medically complex children with follow- up within three days had increased readmission risk. Evidence supporting discharge interventions for children with medical complexity is limited. Multi-faceted discharge interventions and post-discharge clinic visits may be effective.

Effectiveness of structured planned post discharge support to patients with chronic obstructive pulmonary disease for reducing readmission rates: a systematic review.

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, characterized by airflow limitation. The disease has a significant impact on the lives of patients and is a challenge for the health care due to readmissions to hospitals. This review aimed to identify, appraise and synthesize the best available evidence on the effectiveness of discharge interventions that can reduce readmission of patients with COPD. Hospitalized patients, aged 18 years or over, who had been diagnosed with COPD and were admitted to hospital due to acute exacerbation. Studies that evaluated discharge interventions that supported patients managing symptoms of COPD. Randomized controlled trials, non-randomized controlled trials, quasi-experimental or cohort studies. Readmission, defined as hospitalization to the same or different hospital for any reason within the following year after discharge. Multiple databases (PubMed, Embase, CINAHL, the Cochrane Library, Pedro, Web of Science, Turning Research Into Practice [Trip] and Scopus) were searched from 1990 to June 2015. Studies published in English or Scandinavian. Two independent reviewers used the standard critical appraisal tool from the Joanna Briggs Institute to assess the methodological quality of studies. All studies were of good methodological quality. The process of data extraction was undertaken independently by two reviewers using tools from the Joanna Briggs Institute. A narrative description of each study was performed. Outcomes were reported as the event rate (ER) in the intervention and control groups. Based on the ER relative risk reduction (RRR), absolute risk reduction (ARR), the number needed to treat (NNT), and relative risk (RR) with 95% confidence intervals were calculated. Continuous data were reported in natural units. This review includes ten studies all testing a mix of interventions. A meta-analysis included six studies, four at 30 days follow-up with RR 0.67 (0.45 to 0.98) and 180 days follow-up with RR 0.74 (0.51 to 1.08). The analysis could not identify a single set of interventions that could be recommended. Post discharge support and interventions in patients with COPD significantly reduce the readmission rate within 30 days after discharge from hospital and the interventions may significantly reduce readmission up to 180 days after initial discharge. This is a significant finding from the clinical and practical perspective.

A high-protein diet during hospitalization is associated with an accelerated decrease in soluble urokinase plasminogen activator receptor levels in acutely ill elderly medical patients with SIRS

Acute illness and hospitalization in elderly individuals are often accompanied by the systemic inflammatory response syndrome (SIRS) and malnutrition, both associated with wasting and mortality. Nutritional support and resistance training were shown to increase muscle anabolism and reduce inflammation in healthy elderly. We hypothesized that nutritional support and resistance training would accelerate the resolution of inflammation in hospitalized elderly patients with SIRS. Acutely admitted patients aged >65 years with SIRS were randomized to an intervention consisting of a high-protein diet (1.7 g/kg per day) during hospitalization, and daily protein supplement (18.8 g) and 3 weekly resistance training sessions for 12 weeks after discharge (Intervention, n=14), or to standard-care (Control, n=15). Plasma levels of the inflammatory biomarkers soluble urokinase plasminogen activator receptor (suPAR), interleukin-6, C-reactive protein (CRP), and albumin were measured at admission, discharge, and 4 and 13 weeks after discharge. The Intervention group had an earlier decrease in suPAR levels than the Control group: −15.4% vs. +14.5%, P=.007 during hospitalization, and −2.4% vs. −28.6%, P=.007 between discharge and 4 weeks. There were no significant effects of the intervention on the other biomarkers. All biomarkers improved significantly between admission and 13 weeks, although with different kinetics (suPAR: −22%, interleukin-6: −86%, CRP: −89%, albumin: +11%). Nutritional support during hospitalization was associated with an accelerated decrease in suPAR levels, whereas the combined nutrition and resistance training intervention after discharge did not appear to affect the inflammatory state. Our results indicate that improved nutritional care during hospitalization may accelerate recovery in acutely ill elderly medical patients.

Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol

BackgroundOne of the most important transitions in the continuum of care for children is discharge to home. Optimal discharge communication between healthcare providers and caregivers (e.g., parents or other guardians) who present to the emergency department (ED) with their children is not well understood. The lack of policies and considerable variation in practice regarding discharge communication in pediatric EDs pose a quality and safety risk for children and their parents.MethodsThe aim of this mixed methods study is to better understand the process and structure of discharge communication in a pediatric ED context to contribute to the design and development of discharge communication interventions. We will use surveys, administrative data and real-time video observation to characterize discharge communication for six common illness presentations in a pediatric ED: (1) asthma, (2) bronchiolitis, (3) abdominal pain, (4) fever, (5) diarrhea and vomiting, and (6) minor head injury. Participants will be recruited from one of two urban pediatric EDs in Canada. Video recordings will be analyzed using Observer XT. We will use logistic regression to identify potential demographic and visit characteristic cofounders and multivariate logistic regression to examine association between verbal and non-verbal behaviours and parent recall and comprehension.DiscussionVideo recording of discharge communication will provide an opportunity to capture important data such as temporality, sequence and non-verbal behaviours that might influence the communication process. Given the importance of better characterizing discharge communication to identify potential barriers and enablers, we anticipate that the findings from this study will contribute to the development of more effective discharge communication policies and interventions.

Barriers to discharge from inpatient rehabilitation: a teamwork approach

PurposeIn order to prevent adverse events during the discharge process, coordinating appropriate community resources, medication reconciliation, and patient education needs to be implemented before the patient leaves the hospital. This coordination requires communication and effective teamwork amongst staff members. In order to address these concerns, the purpose of this paper is to incorporate the TeamSTEPPS principles to develop a discharge plan that would best meet the needs of the patients as they return to the community.Design/methodology/approachThrough a gap analysis, barriers to discharge were identified from the following disciplines: nursing, social work, physical and occupational therapy, psychology, and rehabilitation physician. To improve communication, weekly meetings and twice-weekly huddles were implemented so that concerns regarding discharge obstacles could be identified and resolved. Visibility of discharge dates were improved by use of graduation certificates in patient rooms and green ribbons on patient wheelchairs.FindingsAfter implementation of this discharge intervention, length of stay was reduced providing cost savings to the hospital, patient satisfaction on HCAHP surveys improved and demonstrated patient satisfaction with the discharge process, and readmission rates improved.Originality/valueThis study demonstrated that effective teamwork and communication can improve patient safety and satisfaction during the discharge period.