Postdischarge Clinic Visit Research Articles

Symptom severity trajectories and distresses in patients undergoing video-assisted thoracoscopic lung resection from surgery to the first post-discharge clinic visit.

This study aimed to characterize patients' symptom severity trajectories and distresses from video-assisted thoracoscopic lung resection to the first post-discharge clinic visit. Seventy-five patients undergoing thoracoscopic lung resection for diagnosed or suspected pulmonary malignancy prospectively recorded daily symptom severity on a 0-10 numeric scale using the MD Anderson Symptom Inventory until the first post-discharge clinic visit. The causes of postoperative distresses were surveyed, and symptom severity trajectories were analyzed using joinpoint regression. A rebound was defined as a statistically significant positive slope after a statistically significant negative slope. Symptom recovery was defined as symptom severity of ≤3 in two contiguous measurements. The accuracy of pain severity on days 1-5 for predicting pain recovery was determined using area under the receiver operating characteristic curves. We applied Cox proportional hazards models for multivariate analyses of the potential predictors of early pain recovery. The median age was 70 years, and females accounted for 48%. The median interval from surgery to the first post-discharge clinic visit was 20 days. Trajectories of several core symptoms including pain showed a rebound from day 3 or 4. Specifically, pain severity in patients with unrecovered pain had been higher than those with recovered pain since day 4. Pain severity on day 4 showed the highest area under the curve of 0.723 for predicting pain recovery (P = 0.001). Multivariate analysis identified pain severity of ≤1 on day 4 as an independent predictor of early pain recovery (hazard ratio, 2.86; P = 0.0027). Duration of symptom was the leading cause of postoperative distress. Several core symptoms after thoracoscopic lung resection showed a rebound in the trajectory. Specifically, a rebound in pain trajectory may be associated with unrecovered pain; pain severity on day 4 may predict early pain recovery. Further clarification of symptom severity trajectories is essential for patient-centered care.

Retention of discharge instructions using an interdisciplinary model for at-risk children with cancer: A quality improvement initiative.

We sought to improve caregiver retention of critical initial hospital discharge instructions using a multidisciplinary, team-based intervention for newly diagnosed pediatric cancer patients at high risk for unfavorable outcomes. A multidisciplinary team of pediatric residents, nurses, social workers, pharmacists and hematology/oncology faculty implemented practices to optimize teaching of key discharge material as part of four Plan-Do-Study-Act intervention cycles. An 11-question survey distributed at the first post-discharge clinic visit assessed the efficacy of the intervention, as defined by caregiver retention of critical home instructions. Thirty-nine caregivers of pediatric cancer patients in an urban academic tertiary-care children's hospital took part in this project. Overall retention of key discharge information was greater in the post-intervention cohort compared to the baseline cohort (median total scores: 89 and 63, respectively; p=.001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p=.059), from 0.71 to 0.78 for signs of sepsis (p=.65), from 0.57 to 1.00 for accurate choice of on-call number (p=.004), and from 0.71 to 0.94 for antiemetic management (p=.14). Initiation of our comprehensive cancer-specific program to improve caregiver retention of discharge instructions at the first post-hospitalization clinic visit has been successful and sustainable. This project demonstrated that a multi-disciplinary collaborative team effort increases caregiver retention of critical health information, and this has potential to lead to improved outcomes for patients.

A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care.

Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6months. Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

Efficacy of Monitoring for Multiple Antiplatelet Therapy during Intracranial Stent Placement: A Preliminary Study.

During cerebral aneurysm embolization using intracranial stents, platelet aggregation increases owing to increased wall shear stress and a loss of vascular endothelial function at the stent implantation site. Preoperative multiple antiplatelet therapy was introduced to prevent severe thromboembolic complications due to increased platelet aggregation. However, specific guidelines for the administration and pharmacological evaluation of this therapy do not exist currently. We examined the benefits of perioperative platelet aggregation monitoring in a cohort of patients. We had 377 patients with unruptured intracranial aneurysms who underwent stent-assisted embolization at our hospital between December 2012 and November 2019. We ultimately included 181 patients in our final analysis. These patients were continuously administered aspirin (100 mg/day) and clopidogrel (75 mg/day) for more than 5 days before the procedure to the post-procedural period. Of these patients, 30 patients who underwent light transmission aggregometry (LTA) before procedure, post-procedure (3 days after procedure), and at first post-discharge clinic visit were included as the subjects. The following characteristics were studied: age; sex; presence/absence of hypertension, dyslipidemia, and/or diabetes mellitus; location of aneurysm; type/number of stent; technique for stent placement; duration of preoperative multiple antiplatelet therapy; perioperative platelet aggregation test results; and postoperative ischemic or hemorrhagic complications. Among these 30 patients, the median duration of antiplatelet therapy prior to the preoperative platelet aggregation measurements was 7 (interquartile range [IQR]: 6-8) days, and post-discharge measurement of LTA was performed at a median period of 27 (IQR: 22-35.5) days after procedure. The preoperative, postoperative, and first post-discharge clinic visit LTA values for adenosine diphosphate (ADP)-induced platelet aggregation were 50% (IQR: 44-54%), 42.5% (IQR: 36-48%), and 36% (IQR: 32-40%), respectively. These results represented gradual decrease in LTA values and a significant difference between the preoperative and post-discharge values. The LTA values for collagen aggregation showed a significant difference evident between the preoperative and post-discharge values; preoperative 38% (IQR: 27-60%), postoperative 42% (IQR: 30-58%), post-discharge 28% (IQR: 20-42%), respectively. We had one thromboembolic complication and one hemorrhagic complication. The results indicated that appropriate platelet aggregation monitoring during multiple antiplatelet therapy prevents thromboembolic complications such as stent thrombosis. However, we also found that many patients demonstrated increased postoperative platelet aggregation inhibitory effects due to the postoperative continuation of the same multiple antiplatelet therapy that was used preoperatively. This study demonstrates that postoperative, continuous, oral antiplatelet therapy induces increased platelet aggregation inhibition effects, which may lead to hemorrhagic complications. Therefore, continued platelet aggregation monitoring after surgery may be important to allow for any necessary alterations to the therapeutic dose and regimen.

Improvement in Outpatient Follow-up With a Postdischarge Phone Call Intervention

Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit. This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit. Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001). Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.

The association between patient-reported readiness for hospital discharge and outcomes in patients diagnosed with anxiety disorders: A prospective and observational study.

WHAT IS KNOWN ON THE SUBJECT?: Readiness for hospital discharge (RHD) has been an important topic for nurses. RHD can be measured by the Readiness for Hospital Discharge Scale (RHDS), including 4 subscales: personal status, knowledge, coping ability and expected support. There are few studies that focus on RHD in patients diagnosed with mental disorders. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Improving patient-reported RHD can decrease the risks of unscheduled post-discharge clinic visits, readmission and poor quality of life (QOL) in patients diagnosed with anxiety disorders. Improving patient-reported personal status can decrease the risk of poor QOL in patients diagnosed with anxiety disorders. Improving patient-reported knowledge can decrease the risks of unscheduled post-discharge clinic visits and readmission in patients diagnosed with anxiety disorders. Improving patient-reported expected support can decrease the risk of unscheduled post-discharge clinic visits in patients diagnosed with anxiety disorders. Improving the methods of discharge teaching and anxiety severity can enhance RHD in patients diagnosed with anxiety disorders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses could enhance patient-reported RHD to reduce unscheduled post-discharge medical resource utilization or improve QOL by facilitating knowledge acquisition and skill development and improving social support systems. Nurse managers could add RHD assessment to patients' discharge process and train nurses in the methods of discharge education. Nurses could advance their methods of discharge education, such as listening to and answering patients' questions, choosing a convenient time and engaging in online education. ABSTRACT: Introduction The association between readiness for hospital discharge (RHD) and post-discharge outcomes remains unclear in individuals with anxiety disorders. Aim To explore the factors of RHD and the effect of patient-reported RHD on post-discharge outcomes. Method In the observational study, 373 patients diagnosed with anxiety disorders completed the self-administered Readiness for Hospital Discharge Scale (RHDS) on discharge. After 30days, phone interviews were conducted to collect data on post-discharge outcomes, including self-reported unscheduled medical service utilization, symptom severity and quality of life (QOL). Multiple logistic regression models were built to explore the relationships among sociodemographic characteristics, the RHDS and its subscales, and post-discharge outcomes. Results The unscheduled clinic visits were significantly associated with low RHD, knowledge and expected support. Readmission was significantly associated with low RHD and knowledge. Poor QOL was significantly associated with low RHD and personal status. Delivery, received content and anxiety severity were the predictors of RHD. Discussion Improved RHD is associated with fewer unscheduled clinic visits and readmissions and better QOL. Enhancing discharge education can improve RHD. Implications for practice Nurses should enhance patient-reported RHD to improve post-discharge outcomes by advancing the quality of discharge education in patients diagnosed with anxiety disorders.

Acute Heart Failure: Pearls for the First Posthospitalization Clinic Visit

Abstract Follow-up care after a hospitalization for an acute heart failure exacerbation is an essential component when caring for patients with heart failure. The first posthospitalization clinic visit should focus on transitions of care, symptom assessment and management, and optimization of the patient's treatment plan. Nurse practitioners play a vital role in providing timely and comprehensive follow-up for patients with heart failure. This report will discuss various techniques and clinical pearls for maximizing the benefit of the first postdischarge clinic visit.

Abstract TP169: Knowledge of Hypertension as a Stroke Risk Factor and Use of Home Blood Pressure Monitoring. A Preliminary Report From Comprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Self-monitoring blood pressure (BP) among persons with hypertension is associated with lower BP. The prevalence of BP self-monitoring and factors that may predict this behavior in the early post-acute stroke setting are unknown. Our aim was to identify whether knowledge of high BP as a stroke risk factor, social support, or primary care visits would be independently associated with BP self-monitoring 30 days after discharge in stroke patients. Methods: We utilized data from consenting intervention participants in the Comprehensive Post-Acute Stroke Services (COMPASS) Study, who attended the post-discharge clinic visit, and had a 30-day follow-up call (N=528). The primary outcome was self-reported BP monitoring assessed at the 30-day call. The clinic visit included assessment of risk factor knowledge, social support and other clinical and neurological factors. Odds ratios were obtained using logistic mixed models that adjusted for confounders classified as demographic characteristics and clinical factors. Results: Among 528 patients (mean age 67 (SD=14), 50.9% female, 80.1% white), 435 (82%) reported self-monitored BP at 30 days. Fifty-seven percent of those who noted high BP as a stroke risk factor monitored BP vs 43% of those who did not acknowledge this risk factor. Knowledge of BP as risk factor was significantly associated with monitoring after adjustment for demographic, but not after adjustment for clinical factors (Table). Those with social support and recent PCP visits also had higher odds of self-monitoring than those without support or PCP visits, respectively, though estimates were highly imprecise. Conclusions: Among participants, acknowledging high BP is a stroke risk factor may lead to greater use of self-home BP monitoring at 30 days, although the magnitude of this effect is diminished when adjusted for having a history of hypertension. The COMPASS Study will determine whether BP self-monitoring leads to improved BP control at 90 days.

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<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.

Residents' Exposure to Educational Experiences in Facilitating Hospital Discharges.

There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges. We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital. A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility. Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1-10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P = .004], 0.1 [P = .012], and 0.13 [P = 001], respectively). IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.

37 Clinical workload in a DMP in the first three months post discharge and comparison of hfref and HFpEF

<h3>Background</h3> Continuing high event rates post discharge following management of acute decompensated heart failure (HF) may reflect the lack of uniform application of proven benefit of disease management programmes (DMP). Compromising the application may be the workload associated with this approach, which has not been adequately described. <h3>Methods</h3> All patients admitted with a primary diagnosis of HF were enrolled in a comprehensive DMP encompassing in-patient and out-patient care. Workload was viewed through an assessment of post discharge clinic visits (scheduled and unscheduled), telephonic contact and medication changes. Outcomes measured were mortality and emergency hospitalisations. <h3>Results</h3> 1292 patients were enrolled (male 58.7%; 74.5 yrs; HFrEF 68%). Mortality at one and three months post discharge was 0.3% and 3.8% respectively, with HF readmission of 2.5% and 7.3% respectively. Over the three-month programme duration, there were 5046 clinical visits, with a mean of 3.9 visits/patient, and 0.47 unscheduled visits/patient. Almost 30% of patients required at least one unscheduled visit, most frequently in the first week post discharge. Those with HFrEF had more frequent visits than the HFpEF cohort (4.0 vs. 3.7 visits/patient), which likely reflects increased number of medication titrations. There was a mean of 12.7 calls/patient with outbound calls being dominant. 25.8% of patients had 1 inbound call and 45.7% of patients had &gt;1 during this three-month period. There no differences in frequency of inbound and outbound calls in those with HFrEF vs. those with HFpEF. At discharge, 92.5% of patients were prescribed diuretics. Mean diuretic dose at discharge was 58.7 mg frusemide eq. Mean diuretic dose at three months being 63.1 mg. Alteration of diuretic dose (at least one increase or decrease) occurred in 44.7% of patients with 25.8% having one dose change and 18.9% having &gt;1 dose changes during the three-month programme duration. There was no significant difference in diuretic dose between those with HFrEF vs. HFpEF at either discharge or three months. At discharge 73.7% of the patients were prescribed ACEi with at least one dose alteration in ACEI / ARB occurring in 31.9% during the programme. Dose changes in ACEi/ARB were less common in the HFpEF group but still occurred in approximately 20% of those on an ACEi. At discharge, 67.7% were prescribed beta-blockers, with doses unchanged at 3 months in 57.2%. Epleronone as prescribed in 8.8% on discharge, and in 12.4% at three months, with a mean dose of 24.1 mg. <h3>Conclusion</h3> The workload associated with an intensive cardiology-led DMP in the immediate period post discharge, while significant, reflecting clinical instability and complexity of care, is similar for those with both HFrEF and HFpEF. Given the rapid growth in this patient population, this data should be used to inform appropriate resource organisation for establishing or evolving DMP structures.