-
Orthopedic Nursing 2019The quality of discharge teaching is statistically linked to decreased readmission rates. Nursing most often bears the major responsibility of patient and caregiver... (Review)
Review
The quality of discharge teaching is statistically linked to decreased readmission rates. Nursing most often bears the major responsibility of patient and caregiver teaching. Currently, discharge teaching is complicated by problems including time constraints, patient and caregiver overload, and coexisting comorbidities that add complexity to the patient's care needs at home. Not only are readmissions a preventable cost, more importantly, but they also are a negative patient experience signifying to our patients that they are unable to optimally care for themselves or that their disease or healing is not something they can care for alone. The following is a review of Agency for Healthcare Research and Quality's IDEAL discharge process, common problems in discharge teaching, and nursing's responsibilities with assessing a patient and his or her caregiver for discharge readiness. IDEAL is a structured discharge process with tools to help healthcare organizations improve their discharge process to decrease readmissions rates.
Topics: Evidence-Based Nursing; Hospital Costs; Humans; Nursing Assessment; Patient Discharge; Patient Education as Topic; Patient Readmission
PubMed: 31568123
DOI: 10.1097/NOR.0000000000000601 -
JAMA Network Open Aug 2021Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving communication at discharge through specific interventions has an association with patient-relevant outcomes remains unclear.
OBJECTIVE
To conduct a systematic review and meta-analysis on the association of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes.
DATA SOURCES
PubMed, EMBASE, PsycINFO, and CINAHL were systematically searched from the inception of each database to February 28, 2021.
STUDY SELECTION
Randomized clinical trials that randomized patients to receiving a discharge communication intervention or a control group were included.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers extracted data on outcomes and trial and patient characteristics. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Data were pooled using a random-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.
MAIN OUTCOMES AND MEASURES
The primary outcome was hospital readmission, and secondary outcomes included adherence to treatment regimen, patient satisfaction, mortality, and emergency department reattendance 30 days after hospital discharge.
RESULTS
We included 60 randomized clinical trials with a total of 16 070 patients for the qualitative synthesis and 19 trials with a total of 3953 patients for the quantitative synthesis of the primary outcome. Of these, 11 trials had low risk of bias, 6 trials had high risk of bias, and 2 trials had unclear risk of bias. Communication interventions at discharge were significantly associated with lower readmission rates (179 of 1959 patients [9.1%] in intervention groups vs 270 of 1994 patients [13.5%] in control groups; RR, 0.69; 95% CI, 0.56-0.84), higher adherence to treatment regimen (1729 of 2009 patients [86.1%] in intervention groups vs 1599 of 2024 patients [79.0%] in control groups; RR, 1.24; 95% CI, 1.13-1.37), and higher patient satisfaction (1187 of 1949 patients [60.9%] in intervention groups vs 991 of 2002 patients [49.5%] in control groups; RR, 1.41; 95% CI, 1.20-1.66).
CONCLUSIONS AND RELEVANCE
These findings suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.
Topics: Adult; Aged; Aged, 80 and over; Communication; Female; Humans; Male; Middle Aged; Patient Discharge; Patient Education as Topic; Patient Readmission; Practice Guidelines as Topic
PubMed: 34448868
DOI: 10.1001/jamanetworkopen.2021.19346 -
General Hospital Psychiatry May 2017Patients with factitious disorder or malingering behaviors pose particular problems in acute care settings. We sought to describe a manner to effectively discharge these...
OBJECTIVE
Patients with factitious disorder or malingering behaviors pose particular problems in acute care settings. We sought to describe a manner to effectively discharge these patients and keep further harm, iatrogenic or otherwise, from being inflicted.
METHOD
Once an indication has been identified, the therapeutic discharge can be carried out in a stepwise fashion, resulting in a safe discharge. We outlined how to prepare for, and execute, the therapeutic discharge, along with preemptive consideration of complications that may arise.
RESULTS
Consequences for the patient, physicians, and larger healthcare system are considered.
CONCLUSION
The therapeutic discharge is a safe and effective procedure for patients with deception syndromes in acute care settings. Carrying it out is a necessary element of psychiatric residency and psychosomatic medicine fellowship training.
Topics: Adult; Deception; Factitious Disorders; Humans; Malingering; Patient Discharge; Psychosomatic Medicine; Risk Assessment
PubMed: 28622821
DOI: 10.1016/j.genhosppsych.2017.03.010 -
Annals of Emergency Medicine Jun 2020Delayed access to inpatient beds for admitted patients contributes significantly to emergency department (ED) boarding and crowding, which have been associated with... (Comparative Study)
Comparative Study Review
Delayed access to inpatient beds for admitted patients contributes significantly to emergency department (ED) boarding and crowding, which have been associated with deleterious patient safety effects. To expedite inpatient bed availability, some hospitals have implemented discharge lounges, allowing discharged patients to depart their inpatient rooms while awaiting completion of the discharge process or transportation. This conceptual article synthesizes the evidence related to discharge lounge implementation practices and outcomes. Using a conceptual synthesis approach, we reviewed the medical and gray literature related to discharge lounges by querying PubMed, Google Scholar, and Google and undertaking backward reference searching. We screened for articles either providing detailed accounts of discharge lounge implementations or offering conceptual analysis on the subject. Most of the evidence we identified was in the gray literature, with only 3 peer-reviewed articles focusing on discharge lounge implementations. Articles generally encompassed single-site descriptive case studies or expert opinions. Significant heterogeneity exists in discharge lounge objectives, features, and apparent influence on patient flow. Although common barriers to discharge lounge performance have been documented, including underuse and care team objections, limited generalizable solutions are offered. Overall, discharge lounges are widely endorsed as a mechanism to accelerate access to inpatient beds, yet the limited available evidence indicates wide variation in design and performance. Further rigorous investigation is required to identify the circumstances under which discharge lounges should be deployed, and how discharge lounges should be designed to maximize their effect on hospitalwide patient flow, ED boarding and crowding, and other targeted outcomes.
Topics: Beds; Crowding; Emergency Service, Hospital; Health Plan Implementation; Humans; Inpatients; Patient Admission; Patient Discharge; Patient Safety; Peer Review; Time Factors; United Kingdom; United States
PubMed: 31983501
DOI: 10.1016/j.annemergmed.2019.12.002 -
Professional Case Management 2019Miscommunications during the complex process of discharging patients from acute care facilities can lead to adverse events, patient dissatisfaction, and delays in...
PURPOSE OF STUDY
Miscommunications during the complex process of discharging patients from acute care facilities can lead to adverse events, patient dissatisfaction, and delays in discharge. Brief multidisciplinary discharge rounds (MDRs) can increase communication between stakeholders and shorten a patient's length of stay (LOS). At our tertiary academic medical center, case managers (CMs) have historically been assigned patients by physical unit location rather than by provider teams caring for patients. As a result, medicine teams often interact with several unit-based CMs due to lack of geographically cohorted patients, leading to inefficiency and fragmentation in discharge planning communication. Our aim was to implement and evaluate the impact of multidisciplinary, team-based discharge planning rounds (MDR) for general medicine patients.
PRIMARY PRACTICE SETTING
A tertiary academic medical center.
METHODOLOGY AND SAMPLE
Using the model for continuous improvement, we implemented and optimized MDR on 2 of 4 internal medicine resident ward teams that care for general internal medicine patients, including creation of a multidisciplinary team, improving physician continuity.
RESULTS
During the pilot, 1,584 patients were discharged from all medicine teams-825 from pilot teams and 759 from control teams. The proportion of patients with discharge before noon (DBN) orders was 41.2% on pilot versus 29.6% on control teams. Length of stay was 92.2 hr versus 97.2 hr, and 30-day readmission rate was 16.0% versus 18.3% for the pilot versus control teams, respectively. After the pilot concluded, we continued to have resident continuity on pilot teams but returned to the unit-based CM model. During this time, the proportion of DBN orders and LOS were similar between the pilot and control teams (29.0% vs. 24.3% and 95.8 hr vs. 96.6 hr, respectively). The 30-day readmission rate was 12.6% compared with 18.9% for the pilot versus control teams.
IMPLICATIONS FOR CASE MANAGEMENT PRACTICE
Our team-based MDR pilot improved interdisciplinary relationships and communication and resulted in shorter LOS, earlier discharge times, and lower 30-day readmissions.
Topics: Academic Medical Centers; Adult; Aged; Aged, 80 and over; Colorado; Female; Humans; Interdisciplinary Communication; Intersectoral Collaboration; Length of Stay; Male; Middle Aged; Patient Care Team; Patient Discharge; Patient Readmission; Practice Guidelines as Topic; Tertiary Care Centers
PubMed: 30688821
DOI: 10.1097/NCM.0000000000000318 -
JAMA Psychiatry Jul 2017High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear. (Meta-Analysis)
Meta-Analysis Review
IMPORTANCE
High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear.
OBJECTIVES
To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates.
DATA SOURCES
English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done.
STUDY SELECTION
Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated.
DATA EXTRACTION AND SYNTHESIS
The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years.
MAIN OUTCOMES AND MEASURES
The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators.
RESULTS
A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples.
CONCLUSIONS AND RELEVANCE
The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.
Topics: Hospitals, Psychiatric; Humans; Patient Discharge; Suicide
PubMed: 28564699
DOI: 10.1001/jamapsychiatry.2017.1044 -
Narrative Inquiry in Bioethics 2020The 12 narratives highlight persisting structural failures of health care delivery systems, which marginalize and disempower patients. These systemic failures coalesce...
The 12 narratives highlight persisting structural failures of health care delivery systems, which marginalize and disempower patients. These systemic failures coalesce around three major, sometimes overlapping forces. First, financial incentives drive virtually every aspect of health care. Given high costs of doing business, private and public health care providers alike constantly maneuver to minimize financial risks. Second, upon hospital discharge, many patients fall through the cracks, as they transition from the silo of inpatient facilities into another and separate silo, community-based long-term services and supports. Patients leaving inpatient facilities can find themselves in environments ill-suited to support their needs. Third, structural forces affect communication between patients and their health care providers. In particular, major payors, notably Medicare, punish hospitals financially when patients are readmitted shortly after discharge, leading hospitals to prioritize pre-discharge communication. However, discharge planning is often inadequate, leaving patients without essential information to effectively manage their health.
Topics: Communication Barriers; Delivery of Health Care; Hospitals; Humans; Narration; Patient Discharge; Patient Transfer
PubMed: 33583853
DOI: 10.1353/nib.2020.0066 -
BMC Geriatrics Mar 2020Subgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions... (Randomized Controlled Trial)
Randomized Controlled Trial
Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial.
BACKGROUND
Subgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions and emergency department (ED) presentations. We examine whether these subgroups of "at-risk" older patients benefit more than their counterparts from an evidence-based discharge planning intervention, on the following outcomes: (1) independence in ADL, (2) participation in life roles, (3) unplanned re-hospitalizations, and (4) ED presentations.
TRIAL DESIGN AND METHODS
This study used data from a randomized control trial involving 400 hospitalized older patients with acute and medical conditions, recruited through 5 sites in Australia. Participants receive either HOME, a patient-centered discharge planning intervention led by an occupational therapist; or a structured in-hospital consultation. HOME uses a collaborative approach for goal setting and includes pre and post-discharge home visits as well as telephone follow-up. Characteristics associated with higher risks of adverse outcomes were recorded and at-risk subgroups were created (mild cognitive impairment, walking difficulty, comorbidity, living alone and no support from family). Independence in ADL and participation in life roles were assessed with validated questionnaires. The number of unplanned re-hospitalizations and ED presentations were extracted from medical files. Linear regression models were conducted to detect variation in response to the intervention at 3-months, according to patients' characteristics.
RESULTS
Analyses revealed significant interaction effects for intervention by cognitive status for unplanned re-hospitalization (p = 0.003) and ED presentations (p = 0.021) at 3 months. Within the at-risk subgroup of mild cognitively impaired, the HOME intervention significantly reduced unplanned hospitalizations (p = 0.027), but the effect did not reach significance in ED visits. While the effect of HOME differed according to support received from family for participation in life roles (p = 0.019), the participation observed in HOME patients with no support was not significantly improved.
CONCLUSIONS
Findings show that hospitalized older adults with mild cognitive impairment benefit from the HOME intervention, which involves preparation and post-discharge support in the environment, to reduce unplanned re-hospitalizations. Improved discharge outcomes in this at-risk subgroup following an occupational therapist-led intervention may enable best care delivery as patients transition from hospital to home.
TRIAL REGISTRATION
The trial was registered before commencement (ACTRN12611000615987).
Topics: Activities of Daily Living; Aftercare; Aged; Aged, 80 and over; Australia; Cognitive Dysfunction; Female; Humans; Male; Occupational Therapy; Outcome and Process Assessment, Health Care; Patient Discharge; Patient-Centered Care; Treatment Outcome
PubMed: 32122311
DOI: 10.1186/s12877-020-1494-3 -
British Journal of Nursing (Mark Allen... Feb 2017
Topics: Humans; Length of Stay; Patient Discharge; Practice Guidelines as Topic; State Medicine; United Kingdom
PubMed: 28185498
DOI: 10.12968/bjon.2017.26.3.129 -
Laeknabladid
Topics: Humans; Patient Discharge
PubMed: 31571603
DOI: 10.17992/lbl.2019.10.248