Bridges and Barriers: Patients\u27 Perceptions of the Discharge Process Including Multidisciplinary Rounds on a Trauma Unit

Discharge planning is a complex process and ideally begins early in the patient stay. Despite evidence about the importance of discharge readiness, there is limited literature about the patient\u27s view during this transition. The goal of this study was to explore patient perspectives about the discharge process, including multidisciplinary rounds. Multidisciplinary rounding is a process where care providers from various specialties meet to communicate, coordinate patient care, make decisions, and manage responsibilities. The theme found was “bridges and barriers to discharge.” Participants identified timelines and tasks, communication, social support, and motivation as helpful and medical setbacks, insurance limitations, and infrequent communication as hindrances to the discharge. Future research is recommended examining efficacy of various discharge models and examination of communication and support throughout hospitalization

Patients’ Perceptions of Relative Importance of Discharge Elements (PRIDE) Study

Background: Almost 20% of patients experience potentially preventable adverse events within 30 days of hospital discharge (Forster, et al, 2003). The Agency for Healthcare Research and Quality recommends structured and patient-centered discharge communication to prevent adverse events post-discharge (2018). The Joint Commission mandates information that must be included in all discharge communication including reason for hospitalization, significant findings, procedures and treatment provided, patient\u27s discharge condition, patient and family instructions, and attending physician signature (Horwitz, et al, 2013). There is limited data suggesting how healthcare providers believe discharge communication should be prioritized. Blaine, et al, 2018 cites Discharge Education/Teach-back and Involve Care Team as the aspects perceived by providers as having the highest importance. Sorita, et al, 2017 cites medical history, physical findings, cognitive and functional status at discharge, and rationale for medication changes to be “very important” Patient satisfaction with discharge information strongly correlates to overall satisfaction with hospital care (Waniga, et al, 2016). Surprisingly, there is no data on patient’s perceptions about discharge instruction elements and on the relative importance of discharge information. One study demonstrated that 44% of patients felt that improvements were needed to the areas of formatting/layout, clarity, correcting discrepancies/omitted information (Corser, et al, 2017). Determining how discharge information should prioritized may help to make discharge communication more patient-centered, and prevent readmissions and adverse events

GP perspectives on hospital discharge letters : an interview and focus group study

Background: Written discharge communication following inpatient or outpatient clinic discharge is essential for communicating information to the GP, but GPs’ opinions on discharge communication are seldom sought. Patients are sometimes copied into this communication, but the reasons for this variation, and the resultant effects, remain unclear. Aim: To explore GP perspectives on how discharge letters can be improved in order to enhance patient outcomes. Design & setting: The study used narrative interviews with 26 GPs from 13 GP practices within the West Midlands, England. Method: Interviews were transcribed and data were analysed using corpus linguistics (CL) techniques. Results Elements pivotal to a successful letter were: diagnosis, appropriate follow-up plan, medication changes and reasons, clinical summary, investigations and/or procedures and outcomes, and what information has been given to the patient. GPs supported patients receiving discharge letters and expounded a number of benefits of this practice; for example, increased patient autonomy. Nevertheless, GPs felt that if patients are to receive direct discharge letter copies, modifications such as use of lay language and avoidance of acronyms may be required to increase patient understanding. Conclusion: GPs reported that discharge letters frequently lacked content items they assessed to be important; GPs highlighted that this can have subsequent ramifications on resources and patient experiences. Templates should be devised that put discharge letter elements assessed to be important by GPs to the forefront. Future research needs to consider other perspectives on letter content, particularly those of patients

Validation of Patient and Nurse Short Forms of the Readiness for Hospital Discharge Scale and Their Relationship to Return to the Hospital

Objective: To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits. Data Sources/Study Setting: A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. Study Design Prospective longitudinal design, multinomial logistic regression analysis. Data Collection/Extraction Methods: Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. Principal Findings: Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits. Conclusions: Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk

Disposition and Success of Patients Following Discharge in the Acute Setting

Abstract: Background & Purpose: Many patients are seen in the hospital by physical therapists who also help decide where the patient will go after discharge (e.g., home, rehab hospital, skilled nursing facility) with the goal being the safest and best quality of life. Therapists may use different tests and measures along with their own professional judgment to help make a recommendation for a discharge location. The purpose of this study was to examine how PT’s recommendation for discharge location, POMA score, “6-clicks” score, age, diagnosis, and gender determine patient’s fall/readmission status after being discharged by hospital. Subjects: There were 113 patients in this study. The inclusion criteria for the patients were that they had to have been seen by a physical therapist in the acute care hospital, were given a physical therapist discharge recommendation, and were over the age of 18. Methods: Data was collected from a single community hospital in the Pacific Northwest. The following data were collected: reason for patient admission to the hospital, POMA score, “6-clicks” score, the therapist’s discharge recommendation, patient age, patient gender, and the actual discharge location of the patient. Approximately 30 days following discharge, the patients were contacted via telephone to determine where they went after discharge, if they were readmitted to the hospital within 30 days, or if they experienced a fall since leaving the hospital. Data were analyzed using independent t-tests, chi-square analysis, and receiver operating characteristic (ROC) curves. Results: There were no significant differences between patients’ “6-clicks” scores (p=0.667), POMA scores (p=0.890), or age (p=0.940) when comparing those who experienced a post-discharge fall and those that did not have a fall. No differences in “6-clicks” scores (p=0.815), POMA scores (p=0.753), and age (p=0.735) were found between patients’ who were readmitted and those not readmitted within 30 days of discharge. No associations were found with mismatch-when the actual discharge location was not the same as the physical therapist’s recommendation for discharge (fall p=0.090, readmission p=0.087), medical diagnosis (fall p=0.989, readmission p=0.002*) or gender (fall p=0.737, readmission p=0.250) with patients’ outcomes (reported falls or no falls and readmitted or not readmitted after 30 days from discharge). Areas under the ROC curves with “6-clicks” for fall status (patients who had either fallen or not fallen post discharge 30 days) was 0.463 (95% confidence interval (CI)=0.288, 0.637) and for readmission status (patients who had either readmitted or did not 30 days after discharge) was 0.477 (95% CI=0.351, 0.604). Areas under the curves with POMA scores for fall status was 0.505 (95% CI=0.331, 0.678) and for readmission status was 0.497 (95% CI=0.376, 0.617). Discussion: The POMA, “6-clicks,” and the physical therapist recommendations were not associated with patient falls or readmissions. Because other studies have shown a relationship between “6-clicks” and discharge location, there is a need for more studies that examine this relationship. Future studies should include a larger patient population, from multiple locations to diversify the participants and facilities

Evaluation of a rehabilitation support service after acute stroke: Feasibility and patient/carer benefit

Background: Stroke survivors returning home after discharge from hospital and their carers require support to meet their rehabilitation needs (independence in Activities of Daily Living, exercise, psychosocial support). Voluntary or charitable care providers may be able to address some of these needs. Objective: To explore the feasibility of delivering and evaluating enhanced support to stroke survivors and their carers, with a Rehabilitation Support Worker (RSW). Methods: 16 consecutive stroke survivors and their carers were included. All participants received usual hospital care. Seven of these patients and their carers were also allocated an RSW from a charitable care provider. The RSW accompanied therapy training sessions with the patient, carer and therapist in hospital. On discharge, the RSW visited the patient and carer at home over the initial 6 week post-discharge period to support them in practising rehabilitation skills. Patient function (Barthel Index) and patient/carer confidence were independently assessed at discharge (Week 0). The above assessments and patient/carer mood (GHQ-12) and Carer Giver Strain were also assessed at Weeks 1, 6 and 12. RSWs were interviewed for their views about the service. Results: Participants’ functional ability at Week 1 post-discharge was significantly higher in the RSW group. At 6 and 12 weeks post-discharge, functional ability was not significantly different between groups. Carers in the intervention group were less confident at all time points, however, this was not significant. There was no significant effect on carer strain or well-being. Interviews with RSWs highlighted areas of their training that could be enhanced and the need for greater clarity as to their role. Conclusions: The results showed that a definitive trial of rehabilitation support is feasible. A number of obstacles however would need to be overcome including: difficulty in identifying suitable patients, clarity of the RSW role, and appropriate training content

Nurse and Patient Perceptions of Discharge Readiness in Relation to Postdischarge Utilization

Background: Prevention of hospital readmission and emergency department (ED) utilization will be a crucial strategy in reducing health care costs. There has been limited research on nurse assessment and patient perceptions of discharge readiness in relation to postdischarge outcomes. Objectives: To investigate the association of nurse and patient assessments of discharge readiness with postdischarge readmissions and ED visits. Research Design: Hierarchical regression analysis of readmission or ED utilization using independent nurse and patient assessments of discharge readiness and patient characteristics as explanatory variables, with hospital and unit fixed effects. Subjects: A total of 162 adult medical-surgical patients and their discharging nurses from 13 medical-surgical units of 4 Midwestern hospitals. Measures: Readiness for Hospital Discharge Scale completed independently by patients and their discharging nurses within 4 hours before hospital discharge; Postdischarge utilization (unplanned readmission or ED visit within 30 days postdischarge). Results: Correlations between nurse assessment and patient perceptions of discharge readiness were low (r = 0.15- 0.32). Nurses rated patient readiness higher than patients themselves. Controlling for patient characteristics, nurse readiness for hospital discharge scale score (odds ratio = 0.57, P = 0.05) but not patient readiness for hospital discharge scale score was associated with postdischarge utilization. Conclusions: Nurse assessment was more strongly associated with postdischarge utilization than patient self-assessment. Formalizing nurse assessment of discharge readiness could facilitate identification of patients at risk for readmission or ED utilization before discharge when anticipatory interventions could prevent avoidable postdischarge utilization

Individual Nurse Productivity in Preparing Patients for Discharge Is Associated with Patient Likelihood of 30-Day Return to Hospital

Objective: Applied to value-based health care, the economic term “individual productivity” refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient’s likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits]. Research Design: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission. Patients reported discharge readiness scores; postdischarge outcomes and other variables were extracted from electronic health records. Using the structure-process-outcomes model, we viewed patient readiness for hospital discharge as a proximal outcome of the discharge preparation process and used it to measure nurse productivity in discharge preparation. We viewed hospital return as a distal outcome sensitive to discharge preparation care. Multilevel regression analyses used a split-sample approach and adjusted for patient characteristics. Subjects: A total 522 nurses and 29,986 adult (18+ y) patients discharged to home from 31 geographically diverse medical-surgical units between June 15, 2015 and November 30, 2016. Measures: Patient discharge readiness was measured using the 8-item short form of Readiness for Hospital Discharge Scale (RHDS). A 30-day hospital return was a categorical variable for an inpatient readmission or an ED visit, versus no hospital return. Results: Variability in individual nurse productivity explained 9.07% of variance in patient discharge readiness scores. Nurse productivity was negatively associated with the likelihood of a readmission (−0.48 absolute percentage points, P\u3c0.001) and an ED visit (−0.29 absolute percentage points, P=0.042). Conclusions: Variability in individual clinician productivity can have implications for acute care quality patient outcomes

Cross-cultural Adaptation of the Instrument Readiness for Hospital Discharge Scale - Adult Form

Objective: to perform the cross-cultural adaptation of the Readiness for Hospital Discharge Scale - (RHDS) Adult Form for use in Brazil. Method: a methodological study was conducted in 2015, in Brazil’s federal capital, following the eight stages scientifically established. Results: analysis proved the maintenance of semantic, idiomatic, cultural, and conceptual equivalences and kept both the face and content validity of the original version. The judging committee and the pre-test participants declared they understood the RHDS items and answer scale. Conclusion: the instrument is culturally adapted for Brazil and can be used as one of the stages for planning hospital discharge. Descriptors: Nursing Methodology Research; Transitional Care; Continuity of Patient Care; Patient-Centered Care; Patient Discharg

Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization

Objectives. To determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing. Data Sources. Patient questionnaires, electronic medical records, and administrative data for 1,892 medical–surgical patients from 16 nursing units within four acute care hospitals between January and July 2008. Design. Nested panel data with hospital and unit-level fixed effects and patient and unit-level control variables. Data Collection/Extraction. Registered nurse (RN) staffing was recorded monthly in hours-per-patient-day. Patient questionnaires were completed before discharge. Thirty-day readmission and ED use with reimbursement data were obtained by cross-hospital electronic searches. Principal Findings. Higher RN nonovertime staffing decreased odds of readmission (OR=0.56); higher RN overtime staffing increased odds of ED visit (OR=1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.$11.64 million and U.S.$544,000 annually for the 16 study units. Conclusions. Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge