Discharge Recommendations Research Articles

P048 Assessment of discharge recommendations after radical prostatectomy

P048 Assessment of discharge recommendations after radical prostatectomy

Identifying factors influencing emerging innovations in hospital discharge decision making in response to system stress: a qualitative study

BackgroundThe purpose of this qualitative study was to identify emergent rehabilitation innovations and clinician perceptions influencing their implementation and outcomes related to hospital discharge decision-making during the Coronavirus 2019 pandemic.MethodsRehabilitation clinicians were recruited from the Veterans Affairs Health Care System and participated in individual semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Data were analyzed using a rapid qualitative, deductive team-based approach informed by directed content analysis.ResultsTwenty-three rehabilitation clinicians representing physical (N = 11) and occupational therapy (N = 12) participated in the study. Three primary themes were generated: (1) Innovation: emerging innovations in discharge processes included perceived increases in team collaboration, shifts in caseload prioritization, and alternative options for post-acute care. (2) Recipients: innovations emerged as approaches to communicating discharge recommendations changed (in-person to virtual) and strong patient/family preferences to discharge to the home challenged collaborative goal setting; and (3) Context: the ability of rehabilitation clinicians to innovate and the form of innovations were influenced by the broader hospital system, interdisciplinary team dynamics, and policy fluctuations. Innovations described by participants included (1) use of technological modalities for interdisciplinary collaboration, (2) expansion of telehealth modalities to deliver care in the home, (3) changes in acute care case prioritization, and (4) alternative options for discharge directly to home.ConclusionsOur findings reinforce that rehabilitation clinicians developed innovative strategies to quickly adapt to multiple systems-level factors that were changing in the face of the COVID-19 pandemic. Future research is needed to assess the impact of innovations, remediate unintended consequences, and evaluate the implementation of promising innovations to respond to emerging healthcare delivery needs more rapidly.

Consideration of Early Dynamic Risk Stratification to Guide Discharge from Oncologic Follow-Up in Patients with Differentiated Thyroid Cancer.

Background: The current dogma is a life-long follow-up for patients treated for follicular-derived differentiated thyroid cancers (DTC). Our primary objective was to determine the time to recurrence in a series of DTC patients with an excellent response to therapy 6 months after total thyroidectomy and radioiodine therapy. The secondary objectives were to determine the time to suspicion of recurrence and to identify factors associated with recurrence. Methods: This retrospective cohort study included patients treated for DTC between 2008 and 2012 and in remission 6 months after total thyroidectomy and radioiodine treatment. The criteria for remission were negative imaging and suppressed thyroglobulin (Tg) <0.2 ng/mL or rh-TSH-(recombinant human TSH) stimulated Tg <1 ng/mL according to the 2015 ATA (American Thyroid Association) guidelines. Recurrence was defined by cytologically and/or histologically proven cervical lymph node metastasis or the administration of a second radioiodine treatment. Results: Among 721 patients treated for DTC, 158 were excluded because of persistent disease at 6 months, 71 because of missing follow-up data, and 492 were included. The mean and median follow-up time were 7.0 and 7.9 years (interquartile range IQR [2.1-11.3]). Recurrence occurred for 7 patients (1.4%), 1 initially classified as high recurrence risk, 3 as intermediate, and 3 as low risk according to the 2015 ATA guidelines. All relapses occurred within 10 years after initial management (4 within the first 5 years). For patients with recurrence, rise in Tg and/or suspicious lymph nodes were detected in six out of seven cases in the first 8 years and for the last case 10 years after initial surgery. Conclusion: Low and intermediate recurrence risk DTC patients with excellent response 6 months after total thyroidectomy and radioiodine and in remission 10 years later have an extremely low recurrence risk. Follow-up might be undertaken by primary care providers from this time point. These discharge recommendations should be confirmed by further prospective studies.

Pediatric Hospital Admissions with Concern for Neglect: Correlations Between Neglect Types and Other Clinical and Environmental Risk Factors.

Child neglect is a public health concern with negative consequences that impact children, families, and society. While neglect is involved with many pediatric hospitalizations, few studies explore characteristics associated with neglect types, social needs, and post-discharge care. Data on neglect type, sociodemographics, social needs, inpatient consultations, and post-discharge care were collected from the electronic medical record for children aged 0-5years who were hospitalized with concern for neglect during 2016-2020. Frequencies and percentages were calculated to determine sample characteristics. The Chi-square Test for Independence was used to evaluate associations between neglect type and other variables. The most common neglect types were inadequate nutrition (40%), inability to provide basic care (37%), intrauterine substance exposure (25%), combined types (23%), and inadequate medical care (10%). Common characteristics among neglect types included age less than 1year, male sex, Hispanic ethnicity, public insurance, past involvement with Child Protective Services, and inpatient consultation services (social work, physical therapy, and occupational therapy), and post-discharge recommendations (primary care, physical therapy, and regional center). Neglect type groups varied by child medical history, social needs, and discharge recommendations. Statistically significant associations supported differences per neglect type. Our findings highlight five specific types of neglect seen in an impoverished and ethnically diverse geographic region. Post-discharge care needs should focus on removing social barriers and optimizing resources, in particular mental health, to mitigate the risk of continued neglect. Future studies should focus on prevention strategies, tailored interventions, and improved resource allocations per neglect type and discharge location.

Consistency of Physical Therapist Discharge Recommendations in Acute Care

Introduction: Physical therapists assist with discharge planning for hospitalized patients by making recommendations regarding a patient’s optimal discharge location and ongoing rehabilitation needs. The purpose of this study was to examine the consistency of discharge recommendations made by physical therapists with experience working in an acute care setting, when provided with a set of clinical vignettes describing hospitalized patients. Review of Literature: Considering the complex/multifactorial nature of making discharge recommendations, one would expect there to be inconsistencies among physical therapists. However, we are not aware of a previous study examining the level of consistency for discharge recommendations made by physical therapists, when reviewing a set of clinical vignettes. Subjects: Nineteen physical therapists working in an acute care setting. Methods: The physical therapists were provided with 10 clinical vignettes describing hospitalized patients via an electronic survey distributed across three rehabilitation departments. Each vignette described the patient’s medical condition, past medical history, prior level of function, living situation, key examination findings, and other general characteristics. After independently reviewing each case, the physical therapists selected a discharge recommendation from a list of standard options. Fleiss’ kappa was examined to assess the level of agreement among the physical therapists. Results: Overall, Fleiss’ kappa was 0.28, which reflects fair agreement among the physical therapists. Discussion and Conclusion: The 19 physical therapists who participated in this study only exhibited fair agreement with respect to their discharge recommendations. This relatively low level of agreement suggests that efforts to improve the consistency of discharge recommendations should be explored.

Improving patients’, carers’ and primary care healthcare professionals’ experiences of discharge communication from specialist palliative care to community settings: a protocol for a qualitative interview study

BackgroundPatients who have benefited from specialist intervention during periods of acute/complex palliative care needs often transition from specialist-to-primary care once such needs have been controlled. Effective communication between services is central to co-ordination of care to avoid the potential consequences of unmet needs, fragmented care, and poor patient and family experience. Discharge communications are a key component of care transitions. However, little is known about the experiences of those primarily receiving these communications, to include patients’, carers’ and primary care healthcare professionals. This study aims to have a better understanding of how the discharge communications from specialist palliative care services to primary care are experienced by patients, carers, and healthcare professionals, and how these communications might be improved to support effective patient-centred care.MethodsThis is a 15-month qualitative study. We will interview 30 adult patients and carers and 15 healthcare professionals (n = 45). We will seek a range of experiences of discharge communication by using a maximum variation approach to sampling, including purposively recruiting people from a range of demographic backgrounds from 4–6 specialist palliative care services (hospitals and hospices) as well as 5–7 general practices. Interview data will be analysed using a reflexive thematic approach and will involve input from the research and advisory team. Working with clinicians, commissioners, and PPI representatives we will co-produce a list of recommendations for discharge communication from specialist palliative care.DiscussionData collection may be limited by the need to be sensitive to participants’ wellbeing needs. Study findings will be shared through academic publications and presentations. We will draft principles for how specialist palliative care clinicians can best communicate discharge with patients, carers, and primary care clinicians. These will be shared with clinicians, policy makers, commissioners, and PPI representatives and key stakeholders and organisations (e.g. Hospice UK) and on social media. Key outputs will be recommendations for a specialist palliative care discharge proforma.Trial registrationRegistered in ISRCTN Registry on 29.12.2023 ref: ISRCTN18098027.

The Cost of Poverty: The Relationship Between Insurance Status, Length of Stay, and Discharge Disposition in Trauma Patients.

Insurance status (IS) is known to be associated with length of stay (LOS). The impact of IS on excess LOS (ELOS), days between medical readiness and discharge date, has not been explored. We conducted a retrospective study of patients with pelvic fractures at a level I trauma center. Outcomes included ELOS (primary), discharge disposition (secondary), and ELOS-associated complications (secondary). 185 patients were included. Uninsured patients were the youngest and had the least baseline comorbidities (31.3 years (median), Charlson Comorbidity Index (CCI) .1) while publicly insured patients were the oldest and had the most baseline comorbidities (58.4 years (median), CCI 2.32). Excess LOS and associated complications did not differ among groups. After regression analysis, UIPs had longer LOS than PRPs (2.07 days, 95% CI .28-3.85). UIPs were recommended to go to inpatient rehabilitation 51.6% of the time but were discharged home 93.6% of the time; 81.0% of these changes were attributed to insufficient financial resources. Excess LOS and complications associated with ELOS were not associated with IS. Although UIPs were younger and had fewer baseline comorbidities, they had longer LOS after regression analysis. While discharge recommendations differed based on insurance status, UIPs had limited access to rehabilitation due to financial disparities. Despite initial treatment team recommendations, UIPs had to be sent home as their lack of insurance precluded inpatient rehabilitation placement.

Virtual Interprofessional Education: Team Collaboration in Discharge Planning Simulation.

This study assessed the effectiveness of a virtual interprofessional education (IPE) discharge planning simulation, focusing on collaborative patient education, and recommendations for hospital discharge. An acute care hospital. The study utilized a virtual IPE discharge planning simulation for health care students from six different programs. The simulation involved prebriefing, icebreaker, team meeting, patient interaction, and debriefing. Assessment included pre- and post-IPE surveys that included the Interprofessional Education Collaborative (IPEC) Competency Self-Assessment Tool, and video analysis using the Modified McMaster-Ottawa Rating Scale. Student participants from diverse health care programs ( n =143) included nursing ( n = 20), occupational therapy ( n = 21), physical therapy ( n = 42), physician assistant ( n = 38), respiratory therapy ( n = 3), and social work ( n = 19). All programs except respiratory therapy showed significant improvement in IPEC Competency scores post-IPE, with positive outcomes for understanding other professions' roles. Students' self-reported perceptions of team performance were rated highly in various categories. Video analysis demonstrated strong interrater reliability for team scores. Effective hospital discharge planning is vital for cost reduction and patient care improvement. IPE emphasizes collaborative learning among health care students. Previous studies highlight positive outcomes from IPE discharge planning, including virtual formats. This virtual IPE discharge planning simulation significantly improved students' understanding and collaboration competencies, evident in increased IPEC scores across five professions.

"IT's too much to do alone": A mixed-methods exploration of patient experiences implementing emergency department management plans for chronic pain.

To explore the experiences of socio-culturally diverse community members attempting to manage their chronic pain and enact evidence-based management plans following an index Emergency Department (ED) visit. A convergent parallel mixed-methods design with qualitative interviews and descriptive analysis was undertaken in two public hospitals in a multicultural region in Sydney, Australia. Consecutive adults were recruited from culturally and linguistically diverse (CALD: n=45) or Australian-born (n=45) backgrounds, who presented to the ED for a chronic neuromusculoskeletal pain condition. Consenting participants were prescribed an individualised chronic pain management plan following examination by a physiotherapist, who collected standardised measures of pain and health literacy. Six months later, participants underwent a structured phone survey regarding their pain status and whether they had actioned management plans. Participants were invited to participate in a semi-structured interview. Six-month data were available for 82 of 90 participants who attended the ED and consented to the baseline assessment (40 CALD and 42 Australian-born). Participants were 52% females, predominately middle-aged (mean age 54.7years), with an overall mean symptom duration of 10years (SD 9.0). At 6months, there were nine representations by six CALD participants and 23 by nine Australian-born participants. Overall, 52% reported unchanged pain, 24% were worse and 23% improved, with similar action plan progress for CALD (58%) and Australian-born (53%) participants. Pain features and health literacy were similar, irrespective of progress with pain management plans. From 41 participants who consented to phone interviews, three themes emerged to explain their progress with recommendations: 'illness model', 'urgency' and 'control orientation'. Patients presenting to the ED with chronic pain might be more likely to action discharge recommendations if primary care providers identify patient-specific and contextual barriers to implementation.

Abstract TP51: Improving Prescriptions of Cardiovascular-Effective Anti-Diabetic Medications in Patients With Stroke and Type 2 Diabetes

Background and Issue: Type 2 diabetes (DM2) and cardiovascular (CV) disease pose significant risks for ischemic stroke, with a heightened impact on marginalized and under-resourced communities. Despite known CV benefits of newer anti-diabetic medications like glucagonlike peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose co-transporter-2 (SGLT2) inhibitors, these medications are under prescribed. To improve utilization, we conducted a quality improvement (QI) project to enhance prescription rates for these medications. The QI initiative focused on improving diabetes education and ensuring appropriate hypoglycemic medications were provided at discharge, with an aim of reducing the incidence of recurrent strokes. Purpose: The goal of this QI initiative was to improve prescription rates of GLP-1 R or SGLT2 inhibitors in eligible patients with stroke. Method: An assessment of current diabetic referral practices and medical therapy management were conducted, and an algorithm aimed at streamlining referrals for diabetic consults for patients with stroke developed. A diabetic educator or advanced practice nurse was consulted for patients with stroke and elevated A1c. Patients were then evaluated for qualification and use of GLP-1 RA or SGLT2 inhibitors, and discharge recommendations provided. A stroke registry was used to conduct a retrospective analysis of cases with stroke and DM2 for discharged prescriptions of GLP-1 R or SGLT2 inhibitors. Pre-implementation data from October 2021 to March 2022 were compared to post-implementation data from October 2022 to March 2023. Results: A review of 273 cases was completed. Prior to the QI implementation, 14.2% (19 of 134) of cases admitted for stroke with a secondary diagnosis of DM2 and elevated A1c were discharged home on a GLP-1 RA or SGLT2 inhibitor compared with 28.8% (40 of 139) of cases post implementation. Conclusion: Implementation of a QI process aimed at increasing the number of written discharge prescriptions for DM2 medications with proven CV benefits demonstrated a substantial increase in the number of written prescriptions for these medications at discharge.

Management of acute COPD exacerbations in the internal medicine departments in Israel-a national survey.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Acute exacerbations of COPD (AECOPD) drastically affect the clinical course of the disease. We aimed to evaluate the treatment of AECOPD in the internal medicine departments in Israel, nationwide. The COPD Israeli survey (COPDIS) is the first national survey of patients admitted with AECOPD to internal medicine departments between 2017 and 2019. The survey includes prospective (n = 344) and retrospective (n = 1,166) data from 13 medical centers. We analyzed the pre-hospital, in-hospital, and pre-discharge care. Hospital evaluation, outcomes and discharge recommendations were assessed as well. The mean (±SD) age was 74 (±8) years, and 54% were males. 74% had comorbidities, and 88% had a diagnosis of COPD in their history. 70% of the patients received systemic steroids and antibiotics during their hospitalization, yet upon discharge, a lower rate of antibiotics prescription (10%) was found. Treatment with most long-acting bronchodilators dramatically dropped during admission, compared with their pre-hospital use. Overall, a long-acting bronchodilator (LABD) was used by 47% before admission, 28% in-hospital, and was prescribed to 54% at discharge. The discharge plan included a referral to pulmonary rehabilitation in only 11% and a smoking cessation recommendation in 43% of active smokers. The in-hospital mortality was 3% and the 1-year mortality rate was 25%. In multivariate analysis, performing a chest X-ray (adjusted OR 0.64, 95% CI 0.46-0.90) and prescribing LABD at discharge (AOR 0.73, 95% CI 0.57-0.95) were independent predictors for lower 1-year mortality. Our results demonstrate AECOPD characteristics in Israel, and highlight several important gaps in AECOPD healthcare, which must be addressed to improve patient care.

Metabolic monitoring of pediatric patients prescribed second-generation antipsychotic medication.

The prevalence of psychotropic medication prescription use in youth has increased over the past several years. Despite recommendations and practice parameters established by the American Diabetes Association-American Psychiatric Association (ADA-APA) outlining metabolic monitoring of patients prescribed second-generation antipsychotic (SGA) medication, monitoring adherence for the pediatric patient population remains inadequate. This project aimed to improve metabolic monitoring of pediatric patients prescribed SGAs and discharge recommendations for follow-up monitoring within a small, child, and adolescent psychiatric hospital. This project compared metabolic monitoring adherence rates pre and postimplementation of a metabolic monitoring organizational policy developed to provide procedural guidance, using ADA-APA guidelines. Participants included prescribing clinicians (physicians and psychiatric nurse practitioners). Phase 1 chart reviews found no records of fasting blood glucose, fasting lipid profile or waist circumference. Following project implementation, chart review found that fasting blood glucose and fasting lipid profile was recorded in 21 (72.4%) of the charts, and waist circumference was recorded in 18 (62.1%) of the charts for patients prescribed SGA medication. For patients discharged on an SGA, written recommendations for follow-up metabolic monitoring improved from 13% to 70% (<0.001). Implementing an organizational metabolic monitoring policy and protocol can improve clinician adherence to ADA-APA guidelines for recording in-patient monitoring of metabolic parameters and discharge recommendations for pediatric patients prescribed SGA medication.

Postdischarge Video Visits for Adherence to Hospital Discharge Recommendations: A Randomized Clinical Trial

ObjectiveTo determine whether a postdischarge video visit with patients, conducted by hospital medicine advanced practice providers, improves adherence to hospital discharge recommendations. Patients and MethodsWe conducted a single-institution 2-site randomized clinical trial with 1:1 assignment to intervention vs control, with enrollment from August 10, 2020, to June 23, 2022. Hospital medicine patients discharged home or to an assisted living facility were randomized to a video visit 2-5 days postdischarge in addition to usual care (intervention) vs usual care (control). During the video visit, advanced practice providers reviewed discharge recommendations. Both intervention and control groups received telephone follow-up 3-6 days postdischarge to ascertain the primary outcome of adherence to all discharge recommendations for new and chronic medication management, self-management and action plan, and home support. ResultsAmong 1190 participants (594 intervention; 596 control), the primary outcome was ascertained in 768 participants (314 intervention; 454 control). In intervention vs control, there was no difference in the proportion of participants with the primary outcome (76.7% vs 72.5%; P=.19) or in the individual domains of the primary outcome: new and chronic medication management (94.1% vs 92.8%; P=.50), self-management and action plan (76.5% vs 71.5%; P=.18), and home support (94.1% vs 94.3%; P=.94). Women receiving intervention vs control had higher adherence to recommendations (odds ratio, 1.77; 95% CI, 1.08-2.91). ConclusionIn hospital medicine patients, a postdischarge video visit did not improve adherence to discharge recommendations. Potential gender differences in adherence require further investigation.Clinicaltrials.gov number, NCT04547803.

How oral intake, mobility, and activity measures can inform discharge recommendations: A retrospective analysis of hospitalized inmate and non-inmate COVID-19 patients.

Patients who were incarcerated were disproportionately impacted by COVID-19 compared to the general public. Further, the impact of multidisciplinary rehabilitation assessments and interventions on the outcomes of patients admitted to the hospital with COVID-19 is limited. To compare functional outcomes of oral intake, mobility, and activity between inmates and non-inmates who were diagnosed with COVID-19 and examine the relationships among these functional measures and discharge destination. A retrospective analysis was performed on patients admitted to the hospital for COVID-19 at a large academic medical center. Scores on functional measures including Functional Oral Intake Scale (FOIS) and Activity Measure for Post-Acute Care (AM-PAC) were collected and compared between inmates and non-inmates. Binary logistic regression models were used to evaluate the odds of 1) whether patients were discharged to the same place they were admitted and 2) patients being discharged with a total oral diet with no restrictions. Independent variables were considered significant if the 95% CIs of the odds ratios (ORs) did not include 1.0. A total of 83 patients (inmates, n=38; non-inmates, n=45) were included in the final analysis. There were no differences between inmates and non-inmates on initial (P=.39) and final FOIS scores (P=.35) or on initial, final, or change scores (P>.05) on the AM-PAC. When examining separate regression models using AM-PAC mobility or AM-PAC activity scores as independent variables, greater age upon admission decreased the odds (OR=0.922; 95%CI=0.875 to 0.972 and OR=0.918; 95%CI=0.871 to 0.968) of patients being discharged with a total oral diet with no restrictions. The following factors increased the odds of patients being discharged to the same place they were admitted from: being an inmate (OR=5.285; 95%CI= 1.334 to 20.931) and (OR=6.083; 95%CI=1.548 to 23.912); "Other" race (OR=7.596; 95%CI=1.203 to 47.968) and (OR=8.515; 95%CI=1.311 to 55.291); and female sex (OR=4.671; 95%CI=1.086 to 20.092) and (OR=4.977; 95%CI=1.146 to 21.615). Results from this study provide an opportunity to learn how functional measures may be used to better understand discharge outcomes in both inmate and non-inmate patients admitted to the hospital with COVID-19 during the initial period of the pandemic.

AssistMED project - a tool for rapid data extraction from textual electronic health records for cardiovascular research- system design and preliminary results

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Higher Education Background Retrospective and observational analyses are an important part of cardiovascular research. The adoption of Electronic Health Records (EHR) improved the availability of medical documentation for research purposes, but rapid data collection is hampered by the predominantly unstructured nature of EHR. A significant proportion of data is textual information that cannot be utilized for research purposes until is manually coded into a database by a healthcare professional through manual chart review- this conventional method is both cost and time- consuming. Text mining could be utilized to accelerate the process, but little is known about attainable data accuracy and estimation of time gain. Purpose We developed a comprehensive text-processing tool for the cardiology field. The algorithm employs advanced text processing based on a specifically designed, vast database of medical terminology, drug lists and echocardiography parameters with a data structure tailored to the needs of cardiovascular research conduction. The algorithm can automatically analyze three types of textual data which are universal parts of discharge summary in Poland: (1) descriptive list of medical diagnoses; (2) discharge recommendations; (3) echocardiography report (if performed). A set of discharge summaries was analyzed with both the conventional method and the algorithm to demonstrate the process of acquisition of basic characteristics of the cohort of patients with atrial fibrillation/flutter (AF/AFl). Methods Discharge summaries of 394 patients hospitalized at one cardiology department were analyzed (1) automatically and (2) manually coded into the database by a healthcare professional utilizing a proprietary developed annotation tool to accelerate the annotation process, minimize errors and calculate total effective data acquisition time. Results The time of manual and automatic data analysis was 19:11 and 0:15 hours respectively. Of the total 394 patients, 319 (81%) had AF/AFl according to both manual identification and the algorithm (full agreement). The characteristics of the study group obtained with manual and automatic method is presented in Table. There was high agreement in the detection of diseases, presence of drug groups and echocardiographic parameters; some differences between the two classifications were noted but did not reach statistical significance. The median CHA2DS2VASc score calculated by the algorithm was 4 (IQR 3-5) versus 4 (IQR 3-5) for the manual method (p=0.92) and HAS-BLED score by the algorithm was 1 (IQR 1-2) versus 1 (IQR 1-2) for the manual method (p=0.98). Conclusions The utilization of the algorithm greatly reduced the time required for basic characteristics of the study group acquisition without significantly compromising the quality of the data. Automatic detection of retrospective study cohorts through the application of text processing techniques from electronic health records in Polish is promising and feasible.

Association of Hospital Readmission Rates With Discharge Disposition for Patients With Psychotic Disorders.

We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission. The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged. In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender. The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.

Quantifying the Risk for Hospital Readmission When Physical Therapist Discharge Recommendations Are Not Followed

Purpose: Studies suggest that implementing physical therapist discharge recommendations decreases 30-day hospital readmissions but may have miscounted readmissions. The purpose of this study was to obtain accurate readmission data and calculate the risk for readmission when therapists' recommendations are not followed. Methods: We conducted this prospective cohort study at a hospital in the Northwestern United States. Two hundred sixty-nine hospitalized participants with physical therapy orders consented to medical record data extraction and participated in a follow-up phone call. We compared physical therapist discharge recommendations to the actual discharge setting and services established for participants as documented in their medical record. Thirty days after discharge, we called participants to ask whether they had been readmitted to any hospital. We then analyzed associations between readmissions and the mismatch of therapist recommendations and participants' actual discharge locations and services received. Results: Twenty-one percent of discharges did not match the location and/or services recommended by the physical therapist. Sixty-six of the 269 participants were readmitted within 30 days. The odds for readmission were 2.3 times greater among participants who did not discharge to the location with the services recommended by their physical therapist. Conclusions: When physical therapist discharge location and services recommendations are not implemented, patients have increased risk of hospital readmission. This finding should inform stakeholders involved in discharge planning on the effect of following recommendations.

Early prediction of patient discharge disposition in acute neurological care using machine learning

BackgroundAcute neurological complications are some of the leading causes of death and disability in the U.S. The medical professionals that treat patients in this setting are tasked with deciding where (e.g., home or facility), how, and when to discharge these patients. It is important to be able to predict potential patient discharge outcomes as early as possible during the patient’s hospital stay and to know what factors influence the development of discharge planning. This study carried out two parallel experiments: A multi-class outcome (patient discharge targets of ‘home’, ‘nursing facility’, ‘rehab’, ‘death’) and binary class outcome (‘home’ vs. ‘non-home’). The goal of this study is to develop early predictive models for each experiment exploring which patient characteristics and clinical variables significantly influence discharge planning of patients based on the data that are available only within 24 h of their hospital admission. MethodOur methodology centers around building and training five different machine learning models followed by testing and tuning those models to find the best-suited predictor for each experiment with a dataset of 5,245 adult patients with neurological conditions taken from the eICU-CRD database.ResultsThe results of this study show XGBoost to be the most effective model for predicting between four common discharge outcomes of ‘home’, ‘nursing facility’, ‘rehab’, and ‘death’, with 71% average c-statistic. The XGBoost model was also the best-performer in the binary outcome experiment with a c-statistic of 76%. This article also explores the accuracy, reliability, and interpretability of the best performing models in each experiment by identifying and analyzing the features that are most impactful to the predictions.ConclusionsThe acceptable accuracy and interpretability of the predictive models based on early admission data suggests that the models can be used in a suggestive context to help guide healthcare providers in efforts of planning effective and equitable discharge recommendations.

Post-discharge early assessment with remote video link (PEARL) initiative for patients discharged from hospital medicine services

ABSTRACT Objectives The COVID-19 pandemic impacted the availability and accessibility of outpatient care following hospital discharge. Hospitalists (physicians) and hospital medicine advanced practice providers (HM-APPs) coordinate discharge care of hospitalized patients; however, it is unknown if they can deliver post-discharge virtual care and overcome barriers to outpatient care. The objective was to develop and provide post-discharge virtual care for patients discharged from hospital medicine services. Methods We developed the Post-discharge Early Assessment with Remote video Link (PEARL) initiative for HM-APPs to conduct a post-discharge video visit (to review recommendations) and telephone follow-up (to evaluate adherence) with patients 2–6 days following hospital discharge. Participants included patients discharged from hospital medicine services at an institution’s hospitals in Rochester (May 2020–August 2020) and Austin (November 2020–February 2021) in Minnesota, US. HM-APPs also interviewed patients about their experience with the video visit and completed a survey on their experience with PEARL. Results Of 386 eligible patients, 61.4% were enrolled (n = 237/386) including 48.1% women (n = 114/237). In patients with complete video visit and telephone follow-up (n = 141/237), most were prescribed new medications (83.7%) and took them as prescribed (93.2%). Among five classes of chronic medications, patient-reported adherence ranged from 59.2% (narcotics) to 91.5% (anti-hypertensives). Patient-reported self-management of 12 discharge recommendations ranged from 40% (smoking cessation) to 100% (checking rashes). Patients reported benefit from the video visit (agree: 77.3%) with an equivocal preference for video visits over clinic visits. Among HM-APPs who responded to the survey (88.2%; n = 15/17), 73.3% reported benefit from visual contact with patients but were uncertain if video visits would reduce emergency department visits. Conclusion In this novel initiative, HM-APPs used video visits to provide care beyond their hospital role, reinforce discharge recommendations for patients, and reduce barriers to outpatient care. The effect of this initiative is under evaluation in a randomized controlled trial.

Therapists Predict Discharge Destination More Accurately Than the AM-PAC “6 Clicks” at Evaluation and Discharge for Patients With Isolated Coronary Artery Bypass Graft

Background: Clinicians and hospital care coordinators seek effective tools to assist with reducing length of stay, delivering appropriate postacute care services, and reducing readmissions for patients following coronary artery bypass grafting (CABG) surgery. Objective: To evaluate whether the discharge recommendation by the Activity Measure for Post-Acute Care (AM-PAC) “6 Clicks” Inpatient Basic Mobility and Daily Activity Short Forms agreed with therapists' recommendation and actual discharge disposition for patients who underwent isolated CABG. Methods: Physical therapists (PTs) and occupational therapists (OTs) recorded their respective AM-PAC “6 Clicks” score on a cohort of consecutive patients admitted for isolated CABG between March and April 2020. The level of agreement was compared between AM-PAC-projected discharge disposition, therapists' recommendation, and actual discharge disposition. Results: There were 58 patients who received discharge recommendations from PTs and OTs following isolated CABG. Upon PT initial evaluation, the AM-PAC “6 Clicks” Basic Mobility tool recommended postacute placement in all 58 (100%) cases, whereas PTs recommended postacute placement for only 1 (2%). Similarly, the AM-PAC “6 Clicks” Daily Activity tool recommended postacute placement in all 58 (100%) cases, whereas OTs recommended discharge to home for 44 (76%) cases and recommended further assessment of discharge needs on the remaining 14 (24%). At the final session, the AM-PAC “6 Clicks” Basic Mobility tool recommended postacute placement in 56 (98%) cases and PTs recommended discharge to home in all 58 (100%) cases. The AM-PAC “6 Clicks” Daily Activity tool recommended postacute placement for 25 (43%) cases, whereas OTs recommended discharge to home for 55 (95%) cases. Nearly all (56; 97%) patients were discharged to home, with the remaining 2 (3%) discharged to postacute placement. The 30- day readmission rate was 2%. Conclusion: We found the PT/OT recommendations were strongly associated with discharge disposition, but that the AM-PAC “6 Clicks” scores had poor agreement with therapists' recommendations and with actual discharge dispositions for patients with isolated CABG. The utility of this tool should be explored in other cardiac patient populations, such as valve replacements with and without sternotomy, and heart failure, to corroborate the results.