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British Journal of Community Nursing Apr 2021Over the past 30 years, the Government has been promoting the transition of care from the acute setting to the community setting. Within the community setting, district... (Review)
Review
Over the past 30 years, the Government has been promoting the transition of care from the acute setting to the community setting. Within the community setting, district nurses are described in the latest reports as endorsers of the care close to home. However, with the surge in hospital discharge, the district nursing workforce is faced with further pressure to cope with the drive to move care into the community. The purpose of this extended literature review (ELR) was to deconstruct the available data on the challenges and hurdles experienced by district nurses to manage hospital discharge. On reviewing the selected data, it was found that fragmented communication between secondary and primary sectors poses problems for effective care in the community. Additionally, the lack of understanding of the district nursing service and its remits creates obstacles for effective hospital discharge. Some practical solutions to resolve these problems are proposed.
Topics: Communication; Humans; Nurses, Community Health; Patient Discharge
PubMed: 33797967
DOI: 10.12968/bjcn.2021.26.4.184 -
British Journal of Nursing (Mark Allen... Oct 2021Patient discharge between acute and secondary care will be viewed differently based on the stakeholder groups involved. Examining these different perceptions may help...
BACKGROUND
Patient discharge between acute and secondary care will be viewed differently based on the stakeholder groups involved. Examining these different perceptions may help improve the discharge process and the patient journey from hospital to home.
AIMS
To determine the perceptions of community and hospital nursing staff regarding the challenges that exist with the general hospital discharge process for patients with a urinary catheter.
METHODS
A survey was created and sent to a wide range of acute and community nurses and the subscriber list of and .
FINDINGS
Compared with hospital staff, the opinions of community staff were more negative around the discharge process and post-discharge care and materials.
CONCLUSIONS
Results of this survey provide insight into the perceptions of nursing staff into general patient discharge for those with a urinary catheter and help identify the challenges that exist on the patient journey from hospital to home.
Topics: Aftercare; Hospitals; Humans; Nursing Staff, Hospital; Patient Discharge; Urinary Catheters
PubMed: 34645349
DOI: 10.12968/bjon.2021.30.18.S8 -
Nursing For Women's Health Jun 2021To improve key discharge metrics and achieve more consistency in clinical care, a team at our large health care system developed and implemented the use of an obstetric...
To improve key discharge metrics and achieve more consistency in clinical care, a team at our large health care system developed and implemented the use of an obstetric milestone pathway (OMP). The OMP was integrated into daily multidisciplinary discharge rounds, during which nurses discussed the plan of care and progress toward discharge for each woman and her newborn. The OMP provided nursing staff with a tool for implementing a plan of care and for preparing a woman and her newborn for discharge. Use of the OMP was associated with a decrease in clinical errors, improved patient satisfaction scores, and decreased costs related to length of stay. By using Six Sigma techniques and gaining participation of front-line staff, our team developed a clinical pathway intended to improve the quality, safety, and efficiency of maternal/newborn care.
Topics: Evidence-Based Practice; Female; Health Plan Implementation; Humans; Infant, Newborn; Length of Stay; Patient Care Team; Patient Discharge; Pregnancy; Teaching Rounds
PubMed: 33905672
DOI: 10.1016/j.nwh.2021.03.002 -
Urologic Oncology Feb 2022Hospital readmission is associated with adverse outcomes and increased cost, and as such, has been identified as a metric for surgical quality and a target for shifts in...
PURPOSE
Hospital readmission is associated with adverse outcomes and increased cost, and as such, has been identified as a metric for surgical quality and a target for shifts in health policy. However, the disposition of patients who undergo radical cystectomy for bladder cancer and the association between discharge locations and readmission rates is poorly understood. Understanding the patterns and characteristics of readmission after radical cystectomy will help inform discharge planning and expectations and may have long-term impacts on quality and cost of care delivery. We hypothesize that patients will have varying readmission rates based on their discharge location.
MATERIALS AND METHODS
An observational analysis of the Nationwide Readmissions Database was performed for all patients who underwent elective radical cystectomy in 2016 to 2017. The patients were grouped by the following criteria: whether they were discharged home, home with care, or to a facility. Univariate analysis was performed using the Chi-square test for categorical variables and the Kruskal-Wallis test for continuous variables. A multivariable logistic regression was conducted to evaluate if discharge locations impact patient readmissions at 30- and 90-days.
RESULTS
The final dataset included 4,947 patients discharged home with care, 2,127 patients discharged to home or self-care, and 1,232 patients discharged to a facility. Discharge to a facility was strongly associated with higher 30-day (OR 1.49, CI 1.26-1.76) and 90-day readmission rates (OR 1.46, CI 1.23-1.74). Additionally, home health care was strongly associated with increased 30-day readmission rates (OR 1.22, CI 1.08-1.37) relative to routine discharge home.
CONCLUSIONS
Our analysis suggests that discharge location independently predicts readmission following RC. Further study with more granular patient- and system-level data may aid in identifying structural characteristics and processes that can reduce readmissions and their associated economic impact, while maintaining quality of care delivered.
Topics: Aged; Cystectomy; Female; Humans; Male; Patient Discharge; Treatment Outcome
PubMed: 34393041
DOI: 10.1016/j.urolonc.2021.07.020 -
JAMA Network Open Feb 2022Sepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an...
IMPORTANCE
Sepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown.
OBJECTIVE
To identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED).
DESIGN, SETTING, AND PARTICIPANTS
This cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care.
EXPOSURES
Patient demographic and clinical characteristics, health system parameters, and ED attending physician.
MAIN OUTCOMES AND MEASURES
Information on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders.
RESULTS
Among 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P < .001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P < .001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P < .001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42.
CONCLUSIONS AND RELEVANCE
In this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.
Topics: Aged; Ambulatory Care; Cohort Studies; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Odds Ratio; Patient Discharge; Practice Guidelines as Topic; Prevalence; Retrospective Studies; Risk Factors; Sepsis; Treatment Outcome; Utah
PubMed: 35142831
DOI: 10.1001/jamanetworkopen.2021.47882 -
The Laryngoscope Jan 2021Hospital length of stay (LOS) and throughput are critical issues for hospitals. Late hospital discharges contribute to bottlenecks in the emergency department, overcrowd...
OBJECTIVES/HYPOTHESIS
Hospital length of stay (LOS) and throughput are critical issues for hospitals. Late hospital discharges contribute to bottlenecks in the emergency department, overcrowd surgical and procedural areas, and limit patient tertiary-care center transfers. Our goal was to increase discharge by noon (DCBN) percentage from 8% to over 50% in a sustainable manner.
STUDY DESIGN
Retrospective Review.
METHODS
We used a multiple time series design and a quality improvement approach. An interdisciplinary improvement team (IIT) identified the main causes contributing to late discharge and then developed and implemented multiple interventions to increase the percentage of DCBN. Admissions and discharge information were obtained for all patients in the otolaryngology service (January 2014-September 2017). The intervention was implemented in July 2015. The primary outcome was the percentage of DCBN per month. Secondary outcomes were LOS, case-mix index (CMI), patient experience, and 30-day readmissions. We analyzed the impact of our intervention and outcomes at the preintervention, peri-intervention, and postintervention periods.
RESULTS
One thousand four hundred sixty-four admissions to the otolaryngology service were included. Throughout the intervention period, the percentage of patients DCBN increased. Analysis of the intervention showed significant DCBN change of 15% in the first versus 42% in the last 12-months (P < .001), and shorter LOS (-1.4 days, P < .001) and lower CMI (-0.6, P < .001) in the DCBN group. Patient satisfaction scores improved by 4% (P < .05), and no difference in 30-day readmission rates (P = .29) was shown.
CONCLUSIONS
This multifaceted intervention improved early discharge and patient experience. Our checklist of key behaviors could be applied throughout other services and hospitals with reproducible success.
LEVEL OF EVIDENCE
4 Laryngoscope, 131:E76-E82, 2021.
Topics: Checklist; Hospital Departments; Humans; Length of Stay; Otolaryngology; Patient Discharge; Patient Readmission; Retrospective Studies; Time Factors
PubMed: 32384165
DOI: 10.1002/lary.28729 -
Quality Management in Health Care 2019The uncertainty and ambiguity of not knowing how many patients will be discharged impact patient throughput in hospitals, causing concerns for responding to demand for...
BACKGROUND
The uncertainty and ambiguity of not knowing how many patients will be discharged impact patient throughput in hospitals, causing concerns for responding to demand for admissions. Understanding the potential number of patients to be discharged can support caregivers, ability to concentrate on the range of interactions that patients require to ensure early discharge. Accurate forecasting of patients expected to be discharged by noon is beneficial in accommodating patients who need services and in achieving sustainable patient satisfaction.
METHOD
Models to predict patient discharge before noon (DBN) were formulated using Holt's double exponential smoothing and Box-Jenkins' methods with the aim of achieving minimal errors in each model. The models are applied to 24 months of weekly patient discharge historic data in a medical observation unit and a short-stay clinical unit of a health care hospital system located on the East Coast of United States.
RESULTS
DBN prediction outcomes were more accurate when applying Box-Jenkins' method than Holt's method. Analysis revealed that the model of ARIMA(3,1,2) is most suitable for forecasting. Upon the outcomes of forecast error metrics, the study identifies the mean absolute percent error for the ARIMA model is 14%.
CONCLUSION
Box-Jenkins forecasting performance is superior in predicting DBN with the least forecast error. Predicted values are significant to decision-making interventions aimed at taking new patients, improving quality patient care, and meeting patient throughput performance goals.
Topics: Hospital Administration; Humans; Models, Statistical; Patient Discharge; Time Factors; United States
PubMed: 31567847
DOI: 10.1097/QMH.0000000000000224 -
Journal of Biomedical Informatics May 2021Patients in intensive care units are heterogeneous and the daily prediction of their days to discharge (DTD) a complex task that practitioners and computers are not...
Patients in intensive care units are heterogeneous and the daily prediction of their days to discharge (DTD) a complex task that practitioners and computers are not always able to solve satisfactorily. In order to make more precise DTD predictors, it is necessary to have tools for the analysis of the heterogeneity of the patients. Unfortunately, the number of publications in this field is almost non-existent. In order to alleviate this lack of tools, we propose four methods and their corresponding measures to quantify the heterogeneity of intensive patients in the process of determining the DTD. These new methods and measures have been tested with patients admitted over four years to a tertiary hospital in Spain. The results deepen the understanding of the intensive patient and can serve as a basis for the construction of better DTD predictors.
Topics: Humans; Intensive Care Units; Patient Discharge; Spain
PubMed: 33839305
DOI: 10.1016/j.jbi.2021.103768 -
Australasian Emergency Care Mar 2022Clinicians have limited evidence on which to base their practice to effectively discharge older people from emergency. The aim of the review was to assess the... (Review)
Review
BACKGROUND
Clinicians have limited evidence on which to base their practice to effectively discharge older people from emergency. The aim of the review was to assess the effectiveness of interventions used for the discharge of older people from the emergency department to their home in the community by emergency clinicians.
METHODS
The PRISMA guidelines were followed. The search comprised seven databases including CINAHL Complete, Medline and EMBASE, and additionally unpublished literature sources including trial registries and theses databases. The results were presented for three outcomes: mortality; emergency department representation after the index visit; and physical function. A narrative analysis was performed.
RESULTS
Twenty-five studies met the inclusion criteria; 13 RCTs and 12 quasi-experimental. Risk of bias was moderate to high. There was a trend towards reduced probability of representing to the emergency department within 3 months of the index visit for individualised focussed elder discharge health interventions. Results were equivocal for other outcomes.
CONCLUSIONS
Greater clarity and consensus is needed to determine the most appropriate discharge measures, screening tools, information sources and discharge roles for the emergency setting. Rigorous multicentre trials to improve the evidence on which to base this aspect of emergency care are required.
Topics: Aged; Emergency Service, Hospital; Humans; Patient Discharge
PubMed: 34112626
DOI: 10.1016/j.auec.2021.01.001 -
Hospital Practice (1995) Feb 2021Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO).
OBJECTIVE
Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO).
METHODS
We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention.
PROGRAM EVALUATION
Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences.
RESULTS
Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time.
CONCLUSION
Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.
Topics: Communication; Comorbidity; Efficiency, Organizational; Humans; Length of Stay; Patient Care Planning; Patient Care Team; Patient Discharge; Patient Readmission; Quality Improvement; Time Factors
PubMed: 32819172
DOI: 10.1080/21548331.2020.1814042