Effect of preceding home-visit nursing on time to discharge in hospitalization for the treatment of behavioural and psychological symptoms of dementia among patients with limited familial care

BACKGROUND

During hospitalization for behavioural and psychological symptoms of dementia (BPSD), it is imperative to build a support system for each patient in the community for after they obtain symptom remission. To this end, patients lacking adequate family support are less likely to be discharged to their own homes and need stronger support systems to be established. This study therefore investigated the effects of home-visit nursing before admission on time to home discharge among patients with limited familial care who were hospitalized for treatment of BPSD.

METHODS

A single-centre chart review study was conducted on consecutive patients admitted from home between April 2013 and September 2015 for treatment of BPSD and who had lived alone or with a working family member. Time to home discharge was compared between patients who had home-visit nursing before their admission and those who did not.

RESULTS

In total, 58 patients were enrolled in the study, of whom 12 had preceding home-visit nursing (PHN group) and 46 did not (non-PHN group). Patients in the PHN group were younger (77.7 ± 4.9 vs. 84.1 ± 6.1 years, P = 0.0011) and had higher Mini-Mental State Examination scores (16.8 ± 7.2 vs 11.8 ± 7.3, P = 0.0287). A multivariate Cox proportional hazard regression analysis adjusted for age and Mini-Mental State Examination scores showed a higher likelihood of discharge to home in the PHN group (hazard ratio: 3.85; 95% confidence interval: 1.27-11.6;, P = 0.017) than in the non-PHN group.

CONCLUSION

Home-visit nursing before admission of BPSD patients for treatment could improve the rate of discharge to home among patients with limited familial care after subsequent hospitalization. Home-visit nursing could also enhance collaborative relationships between social and hospital-based care systems, and early implementation could improve the likelihood of vulnerable patient types remaining in their own homes for as long as possible.

The Framework of NICU-discharge Plan System for Preterm Infants in Iran: Duties, Components and Capabilities

Introduction:

The development of comprehensive discharge plan system Not only, will facilitate the discharge process, increase staff and parent satisfaction, improve the care of preterm infants, also reduce the human error.

Aim:

to determine duties, components and capabilities of NICU discharge plan system as a multidimensional tool for facilitating the complex process of transition preterm infants to the home and support parents for post-discharge care.

Method:

The descriptive and qualitative study conducted in 2017. Firstly by literature review, components of framework were determined in 38 statements under 3 major themes: duties, components, and capabilities and then related questionnaire was provided. Cronbach’s alpha test was used to assess the reliability of the questionnaire. The result was more than 0.82 for all statements of questionnaire. The validity of the instrument was determined based on concepts in the valid scientific texts and comments of experts. The analysis was performed using SPSS software.

Result:

In overall, 29 experts participated in the consensus process. In the duties section, all of the statements reach more than 50% consensus. Among statements of the components and capabilities consensus was achieved in 12 out of 17, 12 out of 16 statements respectively.

Conclusion:

according to survey, checkout infant readiness determined as the main duty of the system. Alarm message for special examination before discharge and parent readiness checklist considered as the most important components. The ability to send alarm message, register and log in system were the key capabilities of the discharge system.

Use of a functional mobility measure to predict discharge destinations for patients admitted to an older adult rehabilitation ward: A feasibility study

OBJECTIVE

To investigate whether the discharge destination for older adults can be predicted using functional mobility as measured by the Modified Elderly Mobility Scale (MEMS), associated with demographic and primary reason for admission variables.

METHODS

A retrospective cohort population audit of 257 patients admitted and discharged from four tertiary older adult rehabilitation wards in a three-month period. A number of predictor variables were considered alongside the discharge destination.

RESULTS

Multinomial statistical modelling established that MEMS prior to (P < 0.001), MEMS on completion (P = 0.009) of rehabilitation physiotherapy and primary reason for admission (P = 0.002) were significant variables to predict discharge destination. The model correctly predicted 71% of observed patient discharge destinations.

CONCLUSION

The MEMS in conjunction with primary reason for admission was able to predict discharge destination with 71% accuracy in a heterogeneous population of older adults following rehabilitation.

Health and social factors associated with a delayed discharge amongst inpatients in acute geriatric wards: A retrospective observational study

AIM

In the English National Health Service there is an increasing interest in understanding the factors associated with delayed discharges in older hospitalized adults. The present study sought to analyze whether clinical frailty was a significant and independent risk factor for having a delayed discharge when the data were controlled for potential health and social confounders.

METHODS

This was a retrospective observational study in an English National Health Service teaching hospital. We analyzed all first hospitalization episodes to the Department of Medicine for the Elderly between 1 May 2016 and 31 July 2016. A delayed discharge was operationally defined as a patient being discharged more than 24 h after his/her last recorded clinically fit date.

RESULTS

A total of 924 cases were analyzed. The independent risk factors for having a delayed discharge were: needing a new package of care (OR 4.05, 95% CI 2.68-6.10), new institutionalization (OR 2.78, 95% CI:1.67-4.62), living alone (OR 1.98, 95% CI 1.40-2.81), delirium (OR 1.79, 95% CI 1.17-2.74) and frailty (i.e. ≥5 on the Clinical Frailty Scale, OR 1.74, 95% CI 1.15-2.63).

CONCLUSIONS

The present results are consistent with previous reports that delayed discharges in older hospitalized patients are mainly related to new formal social care requirements in survivors of acute illness. Frailty was an independent risk factor for delay, but its effect might have been confounded by the unmeasured variable of informal care requirements. Our operational definition of delayed discharge does not mirror the legal definition of delayed transfer of care in England, and the results are not externally valid. Geriatr Gerontol Int 2018; 18: 530-537.

Body Composition Changes in Severely Burned Children During ICU Hospitalization

OBJECTIVES

Prolonged hospitalization due to burn injury results in physical inactivity and muscle weakness. However, how these changes are distributed among body parts is unknown. The aim of this study was to evaluate the degree of body composition changes in different anatomical regions during ICU hospitalization.

DESIGN

Retrospective chart review.

SETTING

Children's burn hospital.

PATIENTS

Twenty-four severely burned children admitted to our institution between 2000 and 2015.

INTERVENTIONS

All patients underwent a dual-energy x-ray absorptiometry within 2 weeks after injury and 2 weeks before discharge to determine body composition changes. No subject underwent anabolic intervention. We analyzed changes of bone mineral content, bone mineral density, total fat mass, total mass, and total lean mass of the entire body and specifically analyzed the changes between the upper and lower limbs.

MEASUREMENTS AND MAIN RESULTS

In the 24 patients, age was 10 ± 5 years, total body surface area burned was 59% ± 17%, time between dual-energy x-ray absorptiometries was 34 ± 21 days, and length of stay was 39 ± 24 days. We found a significant (p < 0.001) average loss of 3% of lean mass in the whole body; this loss was significantly greater (p < 0.001) in the upper extremities (17%) than in the lower extremities (7%). We also observed a remodeling of the fat compartments, with a significant whole-body increase in fat mass (p < 0.001) that was greater in the truncal region (p < 0.0001) and in the lower limbs (p < 0.05).

CONCLUSIONS

ICU hospitalization is associated with greater lean mass loss in the upper limbs of burned children. Mobilization programs should include early mobilization of upper limbs to restore upper extremity function.

Telephone discharge support for frail, vulnerable older people discharged from hospital: Impact on readmission rates - Participant and general practitioner feedback

OBJECTIVE

To assess the use and acceptability to older participants and general practitioners (GPs) of telephone support postdischarge to reduce readmissions.

METHODS

A prospective cohort study of older people after discharge from a specialist geriatric unit, and comparison with a previous cohort. Telephone follow-up calls were made fortnightly for three months. Structured questionnaires were used to obtain feedback from participants and GPs.

RESULTS

Readmission rates were high, 40%, despite the intervention. This rate had significantly increased since the earlier cohort. Almost one-fifth of the sample (19%) were readmitted before the first telephone call. Subsequent readmissions were not related to whether participants had reported deteriorating health during the preceding telephone call. Feedback on the intervention from both participants and GPs was supportive.

CONCLUSIONS

Telephone follow-up as we used it did not reduce readmission rates. However, it was well received and appreciated by participants. It is possible the telephone calls were not made early enough or frequently enough to achieve the desired outcome.

Nutritional status is associated with the return home in a long-term care health facility

Background

The purpose of this study was to determine the association between nutritional status and the return home of older people living in a long‐term care health facility (LCHF).

Methods

A nested case control study was performed in 116 people ≥65 years of age in a single LCHF. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA‐SF) and activities of daily living by the Functional Independence Measure (FIM). The return home, duration of rehabilitation, and the family wanting the patient to return home were obtained from clinical records. Multivariate logistic regression analysis was used to assess whether malnutrition had independent effects on the return home.

Results

The participants included 36 males and 80 females with a mean age of 82 years. Thirty‐seven people returned home while 79 did not. The MNA‐SF showed that 80 subjects were malnourished. Sixty‐six of the participants received rehabilitation for longer than 1 hour per week, while 50 received rehabilitation for <1 hour. The proportion of subjects with malnutrition who returned home was significantly lower (P = .003) than in participants who did not return home. Multivariate logistic regression analysis showed that malnutrition (adjusted odds ratio [AOR], 0.23; 95% confidence interval [CI], 0.08‐0.65; P = .006), total FIM score (AOR, 1.03; 95% CI, 1.01‐1.06; P = .012), and the family wanting the patient to return home (AOR, 9.46; 95% CI, 3.19‐28.12; P < .001) were independently associated with the return home.

Conclusions

Nutritional status is associated with the return home in older people living in LCHF.

Post discharge issues identified by a call-back program: identifying improvement opportunities

OBJECTIVES

The period following discharge from the hospital is one of heightened vulnerability. Discharge instructions serve as a guide during this transition. Yet, clinicians receive little feedback on the quality of this document that ties into the patients' experience. We reviewed the issues voiced by discharged patients via a call-back program and compared them to the discharge instructions they had received.

METHODS

At our institution, patients receive an automated call forty-eight hours following discharge inquiring about progress. If indicated by the response to the call, they are directed to a nurse who assists with problem solving. We reviewed the nursing documentation of these encounters for a period of nine months. The issues voiced were grouped into five categories: communication, medications, durable medical equipment/therapies, follow up and new or ongoing symptoms. The discharge instructions given to each patient were reviewed. We retrieved data on the number of discharges from each specialty from the hospital over the same period.

RESULTS

A total of 592 patients voiced 685 issues. The numbers of patients discharged from medical or surgical services identified as having issues via the call-back line paralleled the proportions discharged from medical and surgical services from the hospital during the same period. Nearly a quarter of the issues discussed had been addressed in the discharge instructions. The most common category of issues was related to communication deficits including missing or incomplete information which made it difficult for the patient to enact or understand the plan of care. Medication prescription related issues were the next most common. Resource barriers and questions surrounding medications were often unaddressed.

CONCLUSIONS

Post discharge issues affect patients discharged from all services equally. Data from call back programs may provide actionable targets for improvement, identify the inpatient team's 'blind spots' and be used to provide feedback to clinicians.

Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department

BACKGROUND

The TRAPID-AMI trial study (High-Sensitivity Troponin-T Assay for Rapid Rule-Out of Acute Myocardial Infarction) evaluated high-sensitivity cardiac troponin-T (hs-cTnT) in a 1-hour acute myocardial infarction (AMI) exclusion algorithm. Our study objective was to evaluate the prognostic utility of a modified HEART score (m-HS) within this trial.

METHODS AND RESULTS

Twelve centers evaluated 1282 patients in the emergency department for possible AMI from 2011 to 2013. Measurements of hs-cTnT (99th percentile, 14 ng/L) were performed at 0, 1, 2, and 4 to 14 hours. Evaluation for major adverse cardiac events (MACEs) occurred at 30 days (death or AMI). Low-risk patients had an m-HS≤3 and had either hs-cTnT<14 ng/L over serial testing or had AMI excluded by the 1-hour protocol. By the 1-hour protocol, 777 (60%) patients had an AMI excluded. Of those 777 patients, 515 (66.3%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 262 (33.7%) patients had an m-HS≥4, with 6 (2.3%) patients having MACEs (P=0.007). Over 4 to 14 hours, 661 patients had a hs-cTnT<14 ng/L. Of those 661 patients, 413 (62.5%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 248 (37.5%) patients had an m-HS≥4, with 5 (2.0%) patients having MACEs (P=0.03).

CONCLUSIONS

Serial testing of hs-cTnT over 1 hour along with application of an m-HS identified a low-risk population that might be able to be directly discharged from the emergency department.

Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage: A Matched Cohort Study

BACKGROUND AND PURPOSE

Delayed cerebral infarction (DCI) is a major source of morbidity and mortality after aneurysmal subarachnoid hemorrhage. We report a novel intervention-stereotactic catheter ventriculocisternostomy (STX-VCS) and fibrinolytic/spasmolytic lavage therapy-for DCI prevention. Outcomes of 20 consecutive patients are compared with 60 matched controls.

METHODS

On the basis of individual treatment decisions, STX-VCS was performed in 20 high-risk aneurysmal subarachnoid hemorrhage patients admitted to our department between September 2015 and October 2016. Three controls matched for age, sex, aneurysm treatment method, and admission Hunt and Hess grade were assigned to each case treated by STX-VCS. DCI was the primary outcome. Mortality and mRS at rehabilitation discharge were secondary outcome parameters. The association between STX-VCS and DCI, mortality, and mRS was assessed by conditional logistic regression.

RESULTS

Stereotactic procedures were performed without surgical complications. Continuous cisternal lavage was feasible in 17 of 20 patients (85%). One adverse event because of cisternal lavage was without sequelae. DCI occurred in 25 of 60 (42%) controls and 3 of 20 (15%) patients with STX-VCS (odds ratio, 0.15; 95% confidence interval, 0.04-0.64). Mortality occurred in 20 of 60 (33%) controls and 1 of 20 (5%) patients with STX-VCS, respectively (odds ratio, 0.08; 95% confidence interval, 0.01 - 0.66). Favorable outcome (mRS≤3) at rehabilitation discharge was observed in 12 of 20 patients with STX-VCS (60%) versus 21 of 60 (35%) matched controls (odds ratio, 0.26; 95% confidence interval, 0.8-0.86).

CONCLUSIONS

STX-VCS was feasible and safe in patients with severe aneurysmal subarachnoid hemorrhage. Initial results indicate that DCI and mortality can be reduced, and neurological outcome may be improved with this method.

Predictors of discharge destination from acute care in patients with traumatic brain injury

INTRODUCTION

Many studies have assessed the predictors of morbidity/mortality of patients with traumatic brain injury (TBI) in acute care. However, with the increasing rate of survival after TBI, more attention has been given to discharge destinations from acute care as an important measure of clinical priorities. This study describes the design of a systematic review compiling and synthesising studies on the prognostic factors of discharge settings from acute care in patients with TBI.

METHODS AND ANALYSIS

This systematic review will be conducted on peer-reviewed studies using seven databases including Medline/Medline in-Process, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PsycINFO, CINAHL and Supplemental PubMed. The reference list of selected articles and Google Scholar will also be reviewed to determine other relevant articles. This study will include all English language observational studies that focus on adult patients with TBI in acute care settings. The quality of articles will be assessed by the Quality in Prognostic Studies tool.

ETHICS AND DISSEMINATION

The results of this review will provide evidence that may guide healthcare providers in making more informed and timely discharge decisions to the next level of care for patient with TBI. Also, this study will provide valuable information to address the gaps in knowledge for future research.

TRIAL REGISTRATION NUMBER

Trial registration number (PROSPERO) is CRD42016033046.

Continuum of Care for Inmates Taking Psychiatric Medications While Incarcerated in Minnesota County Jails

Mental illness is more prevalent among adult inmates in Minnesota county jails than nationally. All 78 Minnesota county jails were surveyed about their continuum-of-care procedures to help ensure that inmates who have mental illness continue to receive psychiatric medications after release. Of the 28 county jails responding to the survey (36%), most estimated that greater than 40% of their inmates receive medication for mental illness during incarceration. But while 89% of respondents reported that inmates are frequently taking medication(s) to treat mental illness at release, prerelease planning for these inmates was rarely undertaken. Few Minnesota jails reported having continuum-of-care procedures in place for inmates who have mental illness when these inmates are released back into the community. Jail staff desire greater collaboration between jails, human services agencies, and community mental health providers to help support discharge planning and enhance the continuum of care for inmates who have mental illness.

Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department

Objective: The aim of this study was to compare the 30-day emergency department (ED) return rate between patients given a Take Home Medication pack (THM) versus a standard paper prescription (SPP) prior to discharge. Methods: This was an observational, prospective cohort study in an urban, university-affiliated, level I trauma center. Patients were identified through daily pharmacy reports. Consecutive adult patients discharged from the ED with either a THM or equivalent SPP were included. For each patient, baseline characteristics including age, gender, primary care provider (PCP), primary language, ethnicity, marital status, and insurance status were recorded from the electronic medical record (EMR). Review of the EMR was used to determine whether patients returned to the ED within 30 days and whether the return visit was for all-causes or for the same complaint targeted by the THM or SPP from the index visit. Similarly, visits to other providers in the health system within 30 days were recorded. Results: A total of 711 patients were included in the study, with 268 receiving a THM and 443 receiving a SPP. In comparison with the SPP group, the THM group was more likely to have an all-cause return (Relative Risk [RR] = 1.7, P < .01). Variables associated with increased odds of returning to the ED within 30 days included study group (adjusted Odds Ratio [aOR]: 1.7), male gender (aOR: 1.6), African American ethnicity (aOR: 3.0), public insurance (aOR: 3.3), and institutional financial assistance (aOR: 5.0). The difference between study groups for index visit complaint-specific returns was not significant. Conclusions: Patients receiving a THM demonstrated a higher all-cause return rate than patients receiving a SPP. A randomized study is needed evaluating the effect of THM on return ED visits.

Place of death for hospice-cared terminal patients with cancer: A nationwide retrospective study in Taiwan

BACKGROUND

Hospice care has been part of the Taiwan health-care system for 20 years. Detailed information on the place of death for terminal cancer patients is lacking. Impending death discharge (IDD) is unique in Taiwan, and our study aims to compare IDD with in-hospice death among terminal cancer patients under hospice care.

METHODS

This retrospective study used claims data of decedents of cancer from the National Health Insurance Research Database of Taiwan from 2007 to 2010.

RESULTS

Of the 22,720 cancer decedents enrolled, 6316 had claims data marked with IDD and 16,404 with in-hospice death. Those with IDD were older; had a shorter hospice stay; and higher rates of gastrointestinal, peritoneal, and pulmonary cancers. The mean daily health-care expenditure was higher in those with IDD, however, the total expenditure of terminal hospice admission was lower than those dying in hospices. Patients who were treated at public hospitals had a higher rate of in-hospice death than those treated at private hospitals. Patients with IDD were positively correlated with increasing age and shorter hospice stay. Patients with IDD were positively correlated with private hospitals, especially religious corporation-based hospitals. Male sex, oropharyngeal cancer, bone/connective/breast cancers, and secondary/metastatic cancers were negatively correlated with IDD.

CONCLUSION

Patients with IDD have characteristics distinct from those dying in hospices. Advanced age and short hospice stays were common in those with IDD, and in-depth investigations were needed. As a unique predying process in Taiwan, relevant health-care issues regarding IDD are warranted for further investigations.

Slick scripts: impact on patient flow targets of pharmacists preparing discharge prescriptions in a hospital with an electronic prescribing system

RATIONALE, AIMS AND OBJECTIVES

Inpatient bed access decreases when ward discharge is delayed. This contributes to prolonged emergency department (ED) length of stay (LOS) which has been associated with increased hospital LOS and mortality. Delays in preparation of discharge medication prescriptions by ward doctors may contribute to delayed ward discharge. This project aimed to evaluate the effect on patient flow of having a pharmacist collaborate with ward doctors to prepare discharge prescriptions at a hospital with an electronic prescribing system.

METHOD

Eight-week pre- and post-intervention study on two surgical wards at a major metropolitan Australian hospital. During the intervention, a project pharmacist (PP) electronically prepared discharge prescriptions, in consultation with ward doctors, which were reviewed by the regular ward pharmacist before being dispensed. Outcome measures, based on hospital performance indicators, included: Percentage of patients transferred to wards from ED within four and six hours of presentation; Median time (minutes) past 9 am that patients were discharged from the wards; Percentage of patients discharged from wards by 9 am; Staff satisfaction.

RESULTS

Pre- and post-intervention, there were 259 and 246 patients transferred from ED to the study wards, respectively. The percentage of patients transferred within four and six hours of presentation did not change. There were 320 and 341 patients discharged, pre- and post-intervention, respectively, who required a discharge prescription. The PP prepared 273 (80%) prescriptions during the post-intervention period. Patients were discharged 57 minutes earlier with the intervention (median 211 vs. 154 minutes past 9 am, P = 0.01). The percentage of patients discharged before 9 am increased from 6% to 12% (P = 0.01). All 26 health-professional respondents (79% response rate) were satisfied with the service and recommended its continuation.

CONCLUSIONS

Pharmacist collaboration with doctors to prepare discharge prescriptions did not impact upon ED access targets, but resulted in patients being discharged earlier.

Inpatient transfer to a care home for end-of-life care: What are the views and experiences of patients and their relatives? A systematic review and narrative synthesis of the UK literature

BACKGROUND

Transfers from hospital or 'hospice palliative care units' to care homes for end-of-life care are an increasingly common part of clinical practice but are a source of anxiety and distress for patients, relatives and healthcare professionals.

AIM

To understand the experiences of patients discharged to care homes for end-of-life care.

DESIGN

Systematic review and narrative synthesis of the UK literature concerning inpatient transfer from a hospital or hospice palliative care unit to a care home for end-of-life care.

RESULTS

The published literature is very limited: only three papers and one conference abstract were identified, all of low quality using Gough's weight of evidence assessment. No papers examined transfer from hospital: all were of transfers from hospices and were retrospective case note reviews. Many patients were reported to have been negative or ambivalent about moving and experienced feelings of anxiety or abandonment when transferred. Relatives were often either vehemently opposed or ambivalent. Although some came to accept transfer, others reported the transfer to have seriously affected their loved one's quality of life and that the process of finding a care home had been traumatic. No studies investigated patients' views prospectively, the views of staff or the processes of decision-making.

CONCLUSION

The UK literature is very limited, despite such transfers being an increasingly common part of clinical practice and a source of concern to patients, relatives and staff alike. Further research is urgently needed in this area, especially studies of patients themselves, in order to understand their experiences and views.

Preparing for post-discharge care of premature infants: Experiences of parents

OBJECTIVES

The study sought to describe the experiences of parents of premature children regarding discharge from the neonatal unit.

METHODS

This was a qualitative study, in which 10 semi-structured interviews were conducted with parents of premature infants upon discharge from the neonatal unit. Data were analyzed following principles of grounded theory; open and axial coding was performed.

RESULTS

The following categories emerged from the analysis of the information: feelings experienced upon discharge, and experience of the discharge as a process; the latter category clearly identified barriers and facilitators. The results highlight that the parents experience ambivalent feelings; joy is mixed with the fear of caring for a premature child at home.

CONCLUSIONS

For parents, discharge of premature children from the neonatal unit is a complex process during which conflicting feelings are experienced. Nursing must develop strategies to involve parents early in the care of their children during the hospital stay.

Effect of Implementation of Continuous Care Model on Mothers' Anxiety of the Children Discharged from the Pediatric Surgical Unit

Introduction:

Child's hospitalization for surgery is a source of anxiety for the child and the family that persists for a long time after discharge. Therefore, it is necessary to provide appropriate solutions in this regard. This study aimed to investigate the effect of implementation of continuous care model on anxiety in mothers of children discharged from pediatric units of educational hospitals of Isfahan University of Medical Sciences in 2016.

Materials and Methods:

In this quasi-experimental study, 64 mothers of children hospitalized in surgical units were categorized in two groups (experimental and control). The intervention was a continuous care model including orientation, sensitization, follow up, and evaluation stages. We used Spielberg's Anxiety Questionnaire to assess mothers’ anxiety before, 1 week, and 1 month after the intervention. Data were analyzed using descriptive statistics, (t-test and analysis of variance) using the Statistical Package for the Social Sciences version 16.

Results:

The results of the study showed that the mean anxiety scores of the experimental group were 58.9, 36, and 31.4, respectively, before, 1 week, and 1 month after the intervention (P < 0.001). These scores were 57.5, 55.8, and 49.7, respectively, for the control group. t-test results showed that the mean anxiety scores of the experimental group were significantly less than that of the control group at 1 week and 1 month after the intervention.

Conclusions:

Based on the results, use of the continuous care model led to a decrease in mothers’ anxiety during their children's discharge from the pediatric surgery units. Therefore, we suggest the implementation of this model in pediatric units.

User Experience and Care Integration in Transitional Care for Older People From Hospital to Home: A Meta-Synthesis

This meta-synthesis aimed to improve understanding of user experience of older people, carers, and health providers; and care integration in the care of older people transitioning from hospital to home. Following our systematic search, we identified and synthesized 20 studies, and constructed a comprehensive framework. We derived four themes: (1) 'Who is taking care of what? Trying to work together"; (2) 'Falling short of the mark'; (3) 'A proper discharge'; and (4) 'You adjust somehow.' The themes that emerged from the studies reflected users' experience of discharge and transitional care as a social process of 'negotiation and navigation of independence (older people/carers), or dependence (health providers).' Users engaged in negotiation and navigation through the interrogative strategies of questioning, discussion, information provision, information seeking, assessment, and translation. The derived themes reflected care integration that facilitated, or a lack of care integration that constrained, users' experiences of negotiation and navigation of independence/dependence.

Consensus statement on anaesthesia for day care surgeries

The primary aim of day-care surgery units is to allow for early recovery of the patients so that they can return to their familiar 'home' environment; the management hence should be focused towards achieving these ends. The benefits could include a possible reduction in the risk of thromboembolism and hospital-acquired infections. Furthermore, day-care surgery is believed to reduce the average unit cost of treatment by up to 70% as compared to inpatient surgery. With more than 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hence, there is an immense opportunity for expansion in day-care surgery in India to ensure faster and safer, cost-effective patient turnover. For this to happen, there is a need of change in the mindset of all concerned clinicians, surgeons, anaesthesiologists and even the patients. A group of nine senior consultants from various parts of India, a mix of private and government anaesthesiologists, assembled in Mumbai and deliberated and discussed on the various aspects of day-care surgery. They formulated a consensus statement, the first of its kind in the Indian scenario, which can act as a guidance and tool for day-care anaesthesia in India. The statements are derived from the available published evidence in peer-reviewed literature including guidelines of several bodies such as the American Society of Anesthesiologists, British Association of Day Surgery and International Association of Ambulatory Surgery. The authors also offer interpretive comments wherever such evidence is inadequate or contradictory.

Discharge recommendation based on a novel technique of homeostatic analysis

OBJECTIVE

We propose a computational framework for integrating diverse patient measurements into an aggregate health score and applying it to patient stability prediction.

MATERIALS AND METHODS

We mapped retrospective patient data from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) II clinical database into a discrete multidimensional space, which was searched for measurement combinations and trends relevant to patient outcomes of interest. Patient trajectories through this space were then used to make outcome predictions. As a case study, we built AutoTriage, a patient stability prediction tool to be used for discharge recommendation.

RESULTS

AutoTriage correctly identified 3 times as many stabilizing patients as existing tools and achieved an accuracy of 92.9% (95% CI: 91.6-93.9%), while maintaining 94.5% specificity. Analysis of AutoTriage parameters revealed that interdependencies between risk factors comprised the majority of each patient stability score.

DISCUSSION

AutoTriage demonstrated an improvement in the sensitivity of existing stability prediction tools, while considering patient safety upon discharge. The relative contributions of risk factors indicated that time-series trends and measurement interdependencies are most important to stability prediction.

CONCLUSION

Our results motivate the application of multidimensional analysis to other clinical problems and highlight the importance of risk factor trends and interdependencies in outcome prediction.

Intensive care discharge summaries for general practice staff: a focus group study

BACKGROUND

Understanding how patients and relatives can be supported after hospital discharge is a UK research priority. Intensive Care Unit (ICU) discharge summaries are a simple way of providing GPs with the information they require to coordinate ongoing care, but little evidence is available to guide best practice.

AIM

This study aimed at better understanding the information needs of GP staff (GPs and practice nurses) supporting former patients of ICUs and their families following discharge from hospital, and identifying the barriers/facilitators associated with ICU-primary care information transfer.

DESIGN AND SETTING

This was a qualitative exploratory study of practices and participants throughout the UK.

METHOD

Audiotaped focus group discussions, complemented by small-group/individual interviews, were conducted with 15 former patients of ICUs, four relatives, and 20 GP staff between June and September 2015. Demographic data were captured by questionnaire and qualitative data were thematically analysed.

RESULTS

Findings suggest variability in discharge information experiences and blurred lines of responsibility between hospital and GP staff, and patients/relatives. Continuity of care was affected by delayed or poor communication from the hospital; GPs' limited contact with patients from critical care; and a lack of knowledge of the effects of critical illness or resources available to ameliorate these difficulties. Time pressures and information technology were, respectively, the most commonly mentioned barrier and facilitator.

CONCLUSION

Effective rehabilitation after a critical illness requires a coordinated and comprehensive approach, incorporating the provision of well-completed, timely, and relevant ICU-primary care discharge information. Health professionals need an improved understanding of critical illness, and patients and families must be included in all aspects of the information-sharing process.

Challenges following discharge from acute psychiatric inpatient care in Japan: patients' perspectives

WHAT IS KNOWN ON THE SUBJECT?: A lack of transitional care covering the period from psychiatric hospital discharge to community mental health care can increase the likelihood of illness recurrence or readmission of discharged patients. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The participants expressed the view that discontinuity between inpatient and community life was a post-discharge challenge after being involuntarily admitted to a psychiatric emergency ward. These challenges arose from the dissatisfaction with inpatient treatment, inability to coordinate post-discharge life WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Patients should be able to disclose their feelings about their own experiences in inpatient care settings and the current challenges in community care settings in an open manner. An advocate should be appointed in acute psychiatric inpatient care settings to reflect patients' own feelings and individual needs to transitional care without bias to inpatient and community care providers.

ABSTRACT

Introduction Psychiatric care in Japan usually comprises inpatient care provided during lengthy hospital stays. Recently, policies for shortening psychiatric hospital stays have been aggressively pursued. However, appropriate transitional care is not always provided for acute psychiatric inpatient care. Aim We elucidated patients' challenges immediately after hospital discharge following acute psychiatric inpatient care to clarify how to improve inpatient care and post-discharge follow-ups. Method This study utilized a qualitative descriptive study design and incorporated patient interviews. Participants comprised 18 patients who experienced involuntary admission following a diagnosis of schizophrenia spectrum disorder. Inductive qualitative content analysis was used to create codes and categories from interview transcripts. Findings The core category of post-discharge challenges that emerged was 'separating life as an inpatient from community life'. This comprised two subcategories: 'dissatisfaction with the inpatient care received' and 'lack of abilities to coordinate lifestyle following discharge'. Discussion Patients should be able to disclose their feelings about their experiences in inpatient care settings and the current challenges in community care settings openly. Implications for practice Advocate (e.g. peer staff) should be appointed in acute psychiatric inpatient care settings to reflect patients' feelings and individual needs to transitional care without bias to inpatient and community care providers.

The Current Landscape of Transitions of Care Practice Models: A Scoping Review

Transitions of care (TOC) are a set of actions to ensure patient coordination and continuity of care as patients transfer between different locations or levels. During transitions associated with chronic or acute illness, vulnerable patients may be placed at risk with fragmented systems compromising their health and safety. In addition, poor care transitions also have an enormous impact on health care spending. The primary objective of this scoping review is to summarize the current landscape of practice models that deliver TOC services in the United States. The secondary objective is to use the information to characterize the current state of best practice models. A search of the PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, International Pharmaceutical Abstracts, National Center for Biotechnology Information at the U.S. National Library of Medicine, and Cochrane Library databases (January 1, 2000-April 13, 2015) for articles pertaining to TOC models, limited to U.S. studies published in the English language with human subjects, gleaned 1362 articles. An additional 26 articles were added from the gray literature. Articles meeting inclusion criteria underwent a second review and were categorized into four groups: background information, original TOC research articles not evaluating practice model interventions, original TOC research articles describing practice models, and systematic or Cochrane reviews. The reviewers met weekly to discuss the challenges and resolve disagreements regarding literature reviews with consensus before progressing. A total of 188 articles describing TOC practice models met the inclusion criteria. Despite the strengths of several quality TOC models, none satisfied all the components recommended by leading experts. Multimodal interventions by multidisciplinary teams appear to represent a best practice model for TOC to improve patient outcomes and reduce readmissions, but one size does not fit all. Best model TOC services must include services along the TOC continuum: pretransition and posttransition, as well as at home and in outpatient health care settings. Studies clearly show that single-modal interventions are rarely successful in reducing readmissions and that successful TOC services must be multimodal and multidisciplinary, and continue throughout the care transition. Utilizing best practice TOC models described in this article as a starting point, practitioners interested in developing their own TOC program should test these tools in new practice environments and add to the body of literature by publishing their findings.

Parents' preparedness for their infants' discharge following first-stage cardiac surgery: development of a parental early warning tool

Aim The aim of this study was to explore parental preparedness for discharge and their experiences of going home with their infant after the first-stage surgery for a functionally univentricular heart.

BACKGROUND

Technological advances worldwide have improved outcomes for infants with a functionally univentricular heart over the last 3 decades; however, concern remains regarding mortality in the period between the first and second stages of surgery. The implementation of home monitoring programmes for this group of infants has improved this initial inter-stage survival; however, little is known about parents' experiences of going home, their preparedness for discharge, and parents' recognition of deterioration in their fragile infant.

METHOD

This study was conducted in 2011-2013; eight sets of parents were consulted in the research planning stage in September, 2011, and 22 parents with children aged 0-2 years responded to an online survey during November, 2012-March, 2013. Description of categorical data and deductive thematic analysis of the open-ended questions were undertaken.

RESULTS

Not all parents were taught signs of deterioration or given written information specific to their baby. The following three themes emerged from the qualitative data: mixed emotions about going home, knowledge and preparedness, and support systems.

CONCLUSIONS

Parents are not adequately prepared for discharge and are not well equipped to recognise deterioration in their child. There is a role for greater parental education through development of an early warning tool to address the gap in parents' understanding of signs of deterioration, enabling appropriate contact and earlier management by clinicians.

Correlational Study of Sleep Apnea Patient Characteristics With Discharge Locations

PURPOSE

To determine if a correlation exists between OSA patient characteristics and the PACU discharge location; and the characteristics of the patients at-risk for low saturation levels, increased number of desaturations, and longer length of stay in the PACU.

DESIGN

Retrospective, correlational study design.

METHOD

Chart review of OSA patients ≥ 18 years old. Correlational analysis was performed between 15 high risk patient variables and the PACU discharge disposition: home or monitored bed. Complications resulting in monitored bed admission were reviewed.

FINDINGS

153 patients' charts were reviewed. The results showed that age>60, ASA classification, anesthesia type and narcotics use in the PACU were significantly correlated (p≤.05) with a patient's discharge disposition.

DISCUSSION

The findings are consistent with other OSA research except BMI was not significant in this study.

CONCLUSION

The results highlighted areas for future research and implications for clinical practice that would enable the perioperative care team to deliver safe care based on evidence.

Quality of Transition From Hospital to Home: The Influence of Nurse- and Patient-Reported Readiness

Identifying those at risk of poor outcomes after hospital discharge is a central focus of health care systems. Our purpose was to better understand whether and how patient- and nurse-assessed readiness for discharge (Pt- and RN-RHDS) is related to patient experiences after discharge. We conducted a prospective survey of 70 Veterans and their assigned nurses on the day of, and again with Veterans 2 weeks after, hospital discharge. The predictive model for post-discharge coping difficulty included educational level ( p = .05) and an interaction between Pt-RHDS ratings and Pt-RN RHDS discordance ( p = .01). The predictive model for patient-reported quality of hospital to home transition experience included Pt-RN RHDS discordance and an interaction between Pt-RHDS and the number of people living with the patient ( p = .05). Our findings demonstrate that agreement between Pt- and RN-RHDS may be an important measure in work aiming to improve patient outcomes post-hospitalization.

Natural Language Processing to Assess Documentation of Features of Critical Illness in Discharge Documents of Acute Respiratory Distress Syndrome Survivors

RATIONALE

Transitions to outpatient care are crucial after critical illness, but the documentation practices in discharge documents after critical illness are unknown.

OBJECTIVES

To characterize the rates of documentation of various features of critical illness in discharge documents of patients diagnosed with acute respiratory distress syndrome (ARDS) during their hospital stay.

METHODS

We used natural language processing tools to build a keyword-based classifier that categorizes discharge documents by presence of terms from four groups of keywords related to critical illness. We used a multivariable modified Poisson regression model to infer patient- and hospital-level characteristics associated with documentation of relevant keywords. A manual chart review was used to validate the accuracy of the keyword-based classifier, and to assess for ARDS documentation during the hospital stay.

MEASUREMENTS AND MAIN RESULTS

Of 815 discharge documents, ARDS was identified in only 111 (13%). Mechanical ventilation was identified in 770 (92%) and intensive care unit (ICU) admission in 693 (83%) of discharge documents. Symptoms or recommendations related to post-intensive care syndrome were included in 306 (38%) of discharge documents. Patient age (older; relative risk [RR] = 0.97/yr, 95% confidence interval [CI] = 0.96-0.98) and higher PaO2:FiO2 (decreasing illness severity; RR = 0.96/10-unit increment, 95% CI = 0.93-0.98) were associated with decreased documentation of ARDS. Being discharged from a surgical (RR = 0.33, 95% CI = 0.22-0.50) compared with a medicine service was also associated with decreased rates of ARDS documentation. The manual chart review revealed 98% concordance between ARDS documentation in the discharge summary and during the hospital stay. Accuracy of the document classifier was 100% for ARDS and mechanical ventilation, 98% for ICU admission, and 95% for symptoms of post-intensive care syndrome.

CONCLUSIONS

In the discharge documents of survivors of ARDS, ARDS itself is rarely mentioned, but mechanical ventilation and ICU stay frequently are. The low rates of documentation of ARDS appear to be concordant with low rates of documentation during the hospital stay, consistent with known underrecognition in the ICU. Natural language processing tools can be used to effectively analyze large numbers of discharge documents of patients with critical illness.

Early discharge as a mediator of greater ICU-level care requirements in patients not enrolled on the AAML0531 clinical trial: a Children's Oncology Group report

Previous data suggest that patients enrolled on clinical trials for treatment of cancer have better overall survival than patients who do not enroll; however, short‐term outcomes relative to trial enrollment and corresponding mediators have not been assessed. A cohort of pediatric patients with newly‐diagnosed acute myeloid leukemia was assembled from the Pediatric Health Information System. We evaluated whether patients not enrolled onto Children's Oncology Group trial AAML0531 had greater intensive care unit (ICU)‐level requirements than enrolled patients and whether early discharge after chemotherapy administration mediated this association. Patients not enrolled on AAML0531 were more likely to be discharged early (aOR = 1.40, 95% confidence interval [CI]: 1.02, 1.90) and to require ICU‐level care (aOR = 2.00, 95% CI: 1.06, 3.78) than enrolled patients, but early discharge explained only a small proportion (12.3%) of the absolute difference in ICU‐level care risk. The direct effect of nonenrollment on the need for ICU‐level care was significant (aOR = 1.89, 95% CI: 1.00, 3.94), whereas the indirect effect mediated through early discharge was not (aOR = 1.07, 95% CI: 0.95, 1.19). Factors other than postchemotherapy discharge strategy drive the difference in ICU utilization by trial enrollment status.

Improving post-operative communication between primary and secondary care: the wound closure information card

Aim To assess and improve the quality of Secondary to Primary Care communication on discharge with a focus on post-surgical wound care.

BACKGROUND

Hospital discharge summaries are the principle means of relaying accurate information back to primary care healthcare providers regarding a patient's hospital attendance and any ongoing care that is required. The quality of these summaries can be quiet varied both nationally and local to our Trust. Subsequently the Surgical Directorate were seeing an increased level of additional emergency communication from Primary Care providers especially in relation to post-operative wound care.

METHODS

A survey was distributed to local Primary Care practitioners to assess satisfaction with the General Surgical Department wound care information located on the discharge summary. Using these results, a wound closure information document was developed and distributed to general practice surgeries, and a patient-held 'wound care' card was piloted for two months. The survey was then repeated to determine the success of the intervention. Findings Post discharge communication was on the whole felt to be of poor quality and lacked a large amount of essential and desirable information. There was a particular absence of relevant information regarding surgical wound closure techniques utilised and their ongoing management. Many Primary Care practitioners acknowledge that their knowledge on this subject can be low. A Trust specific information leaflet combined with a dedicated patient held discharge information card can solve a number of these issues improving Primary and Secondary Care satisfaction and reducing the use of emergency resources and appointments.

Improving handoff communication from hospital to home: the development, implementation and evaluation of a personalized patient discharge letter

OBJECTIVE

To develop, implement and evaluate a personalized patient discharge letter (PPDL) to improve the quality of handoff communication from hospital to home.

DESIGN

From the end of 2006-09 we conducted a quality improvement project; consisting of a before-after evaluation design, and a process evaluation.

SETTING

Four general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the Netherlands.

PARTICIPANTS

All consecutive patients of 18 years and older, admitted for at least 48 h.

INTERVENTIONS

A PPDL, a plain language handoff communication tool provided to the patient at hospital discharge.

MAIN OUTCOME MEASURES

Verbal and written information provision at discharge, feasibility of integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge.

RESULTS

A total of 141 patients participated in the before-after evaluation study. The results from the first phase of quality improvement showed that providing patient with a PPDL increased the number of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation improved because of incorporating the PPDL into the electronic patient record (EPR) and professional education. An average of 57% of the discharged patients received the PPDL upon discharge. The number of discharge conversations also increased.

CONCLUSION

Patients and professionals rated the PPDL positively. Key success factors for implementation were: education of interns, residents and staff, standardization of the content of the PPDL, integrating the PPDL into the electronic medical record and hospital-wide policy.

Difficulties of Portuguese Patients Following Acute Myocardial Infarction: Predictors of Readmissions and Unchanged Lifestyles

PURPOSE

Myocardial infarction can occur due to known risk factors and lifestyle choices. The difficulties that patients experience after discharge can lead to readmission and nonadherence to lifestyle change. The purpose of this study was to analyze the difficulties experienced by patients after hospitalization due to myocardial infarction and to identify the predictors of readmission and unchanged lifestyles.

METHODS

The study used a mixed-methods design across 106 patients who had experienced a first episode of acute myocardial infarction. The data were collected from two patient interviews and the patients' medical records. A logistic regression was used to predict unchanged lifestyle and readmission.

RESULTS

In the first interview, 74.5% of the patients reported receiving information prior to discharge. Six months after discharge, 80.2% mentioned that they had changed their lifestyles, but only 59.4% reported that their health had improved, and 75.5% continued to have concerns regarding their health. Patients described difficulties with regard to psychological problems, family dynamics, professional issues, problems with managing cardiovascular symptoms, and complications associated with hospital interventions. A follow-up assessment revealed that 12.3% of patients had been readmitted for cardiovascular disease.

CONCLUSIONS

The analysis revealed significant predictors of readmission amongst patients with hypertension and three-vessel disease. Specifically, the number of people in the household, per capita income, and a lack of information/education provided at discharge as well as problems related to mental health after discharge predicted unchanged lifestyle. An educational program might be advantageous to clarify doubts and involve patients in their own disease management.

Pain among hospitalized older people with heart failure and their preparation to manage this symptom on discharge: a descriptive-observational study

Globally, heart failure (HF) is one of the major health issues faced by many older people. It causes significant symptom burden that requires ongoing management. This paper reports on a descriptive-observational study undertaken to: (1) describe the prevalence of pain and analgesic prescription usage in hospitalized older HF patients; (2) determine the degree to which these patients are provided with a pain self-management strategy prior to discharge; and (3) determine if the patients' pain self-management strategy has been detailed in the discharge summary. A total of 122 older HF patients were included in this study. Results indicated that moderate to severe pain (Numeric Rating Scale score ≥4) is experienced by a substantial number of older people hospitalized with HF. There is little documented evidence that older people are provided with adequate analgesic prescriptions and the instructions required to effectively manage their pain on discharge to the community.

Discharge Planning and Hospital Readmissions

This study examines the association between the quality of hospital discharge planning and all-cause 30-day readmissions and same-hospital readmissions. The sample included adults aged 18 years and older hospitalized in 16 states in 2010 or 2011 for acute myocardial infarction, heart failure, pneumonia, or total hip or joint arthroplasty. Data from the Hospital Consumer Assessment of Healthcare Providers and Systems measured discharge-planning quality at the hospital level. A generalized linear mixed model was used to estimate the contribution of patient and hospital characteristics to 30-day all-cause and same-hospital readmissions. Discharge-planning quality was associated with (a) lower rates of 30-day hospital readmissions and (b) higher rates of same-hospital readmissions for heart failure, pneumonia, and total hip or joint replacement. These results suggest that by improving inpatient discharge planning, hospitals may be able to influence their 30-day readmissions and increase the likelihood that readmissions will be to the same hospital.

Association of Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries With Ischemic Stroke

BACKGROUND AND PURPOSE

Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. Although studies have suggested improved processes of care in GWTG-Stroke-participating hospitals, it is not known whether this improved care translates into improved clinical outcomes compared with nonparticipating hospitals.

METHODS

From all acute care US hospitals caring for Medicare beneficiaries with acute stroke between April 2003 and December 2008, we matched hospitals that joined the GWTG-Stroke program with similar hospitals that did not. Using a difference-in-differences design, we analyzed whether hospital participation in GWTG-Stroke was associated with a greater improvement in clinical outcomes compared with the underlying secular change.

RESULTS

The matching algorithm identified 366 GWTG-Stroke-adopting hospitals that cared for 88 584 acute ischemic stroke admissions and 366 non-GWTG-Stroke hospitals that cared for 85 401 acute ischemic stroke admissions. Compared with the Pre period (18-6 months before program implementation), in the Early period (0-6 months after program implementation), GWTG-Stroke hospitals had accelerated increases in discharge to home and reduced mortality at 30 days and 1 year. In the Sustained period (6-18 months after program implementation), the accelerated reduction in mortality at 1 year was sustained, with a trend toward sustained accelerated increase in discharge home.

CONCLUSIONS

Hospital adoption of the GWTG-Stroke program was associated with improved functional outcomes at discharge and reduced postdischarge mortality.

Optimal medical therapy for secondary prevention after an acute coronary syndrome: 18-month follow-up results at a tertiary teaching hospital in South Korea

Background

Acute coronary syndrome (ACS) is a fatal cardiovascular disease caused by atherosclerotic plaque erosion or rupture and formation of coronary thrombus. The latest guidelines for ACS recommend the combined drug regimen, comprising aspirin, P2Y₁₂ inhibitor, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, β-blocker, and statin, at discharge after ACS treatment to reduce recurrent ischemic cardiovascular events. This study aimed to examine prescription patterns of secondary prevention drugs in Korean patients with ACS after hospital discharge, to access the appropriateness of secondary prevention drug therapy for ACS, and to evaluate whether to persistently use discharge medications for 18 months.

Methods

This study was retrospectively conducted with the patients who were discharged from the tertiary hospital, located in South Korea, after ACS treatment between September 2009 and August 2013. Data were collected through electronic medical record.

Results

Among 3,676 patients during the study period, 494 were selected based on inclusion and exclusion criteria. The regimen of aspirin + clopidogrel + β-blocker + angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker + statin was prescribed to 374 (75.71%) patients with ACS at discharge. Specifically, this regimen was used in 177 (69.69%) unstable angina patients, 44 (70.97%) non-ST-segment elevation myocardial infarction patients, and 153 (85.96%) ST-segment elevation myocardial infarction patients. Compared with the number of ACS patients with all five guideline-recommended drugs at discharge, the number of ACS patients using them 12 (n=169, 34.21%) and 18 (n=105, 21.26%) months after discharge tended to be gradually decreased.

Conclusion

The majority of ACS patients in this study received all five guideline-recommended medications at discharge from the hospital. However, the frequency of using all of them had been gradually decreased 3, 6, 12, and 18 months after discharge compared with that at discharge. Careful monitoring of adherence on ACS secondary prevention medications may help improve the outcomes of ACS patients in terms of recurrent ischemic cardiovascular events.

Caregiver Perceptions of Hospital to Home Transitions According to Medical Complexity: A Qualitative Study

OBJECTIVE

To explore caregiver needs and preferences for achievement of high-quality pediatric hospital to home transitions and to describe similarities and differences in caregiver needs and preferences according to child medical complexity.

METHODS

Qualitative study using semistructured telephone interviews of 18 caregivers of patients aged 1 month to 18 years discharged from Seattle Children's Hospital between September 2013 and January 2014. Grounded theory methodology was used to elucidate needs and preferences identified to be important to caregivers. Medical complexity was determined using the Pediatric Medical Complexity Algorithm. Thematic comparisons between medical complexity groups were facilitated using a profile matrix.

RESULTS

A multidimensional theoretical framework consisting of 3 domains emerged to represent caregiver needs and preferences for hospital to home transitions. Caregiver self-efficacy for home care management emerged as the central domain in the framework. Caregivers identified several needs to promote their sense of self-efficacy including: support from providers familiar with the child, opportunities to practice home care skills, and written instructions containing contingency plan information. Many needs were consistent across medical complexity groups; however, some needs and preferences were only emphasized by caregivers of children with chronic conditions or caregivers of children with medical complexity. Distinct differences in caregiver preferences for how to meet these needs were also noted on the basis of the child's level of medical complexity.

CONCLUSIONS

Caregivers identified several needs and preferences for enhancement of their sense of self-efficacy during hospital to home transitions. These findings inform quality improvement efforts to develop family-centered transition systems of care that address the needs and preferences of broad pediatric populations.

Natural Language Processing for Cohort Discovery in a Discharge Prediction Model for the Neonatal ICU

OBJECTIVES

Discharging patients from the Neonatal Intensive Care Unit (NICU) can be delayed for non-medical reasons including the procurement of home medical equipment, parental education, and the need for children's services. We previously created a model to identify patients that will be medically ready for discharge in the subsequent 2-10 days. In this study we use Natural Language Processing to improve upon that model and discern why the model performed poorly on certain patients.

METHODS

We retrospectively examined the text of the Assessment and Plan section from daily progress notes of 4,693 patients (103,206 patient-days) from the NICU of a large, academic children's hospital. A matrix was constructed using words from NICU notes (single words and bigrams) to train a supervised machine learning algorithm to determine the most important words differentiating poorly performing patients compared to well performing patients in our original discharge prediction model.

RESULTS

NLP using a bag of words (BOW) analysis revealed several cohorts that performed poorly in our original model. These included patients with surgical diagnoses, pulmonary hypertension, retinopathy of prematurity, and psychosocial issues.

DISCUSSION

The BOW approach aided in cohort discovery and will allow further refinement of our original discharge model prediction. Adequately identifying patients discharged home on g-tube feeds alone could improve the AUC of our original model by 0.02. Additionally, this approach identified social issues as a major cause for delayed discharge.

CONCLUSION

A BOW analysis provides a method to improve and refine our NICU discharge prediction model and could potentially avoid over 900 (0.9%) hospital days.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Readiness for Hospital Discharge, Health Literacy, and Social Living Status

Patient characteristics and lack of preparedness are associated with poor outcomes after hospital discharge. Our purpose was to explore the association between patient characteristics and patient- and nurse-completed Readiness for Hospital Discharge Scale (RHDS). We conducted a prospective study of 70 Veterans being discharged from medical and surgical units. Differences in RHDS knowledge subscale scores were found among literacy levels, with lower perceived knowledge reported for those with marginal or inadequate literacy (p = .03). Differences in RHDS expected support subscale scores were also found, with those who were unmarried and/or living alone (p < .001) anticipating less support upon discharge. No other differences were found. Similar differences were found for the RHDS completed by nurses. These findings suggest that the RHDS appears responsive to differences in health literacy and social environment, adding to evidence of its utility as a tool to identify, and plan interventions for, those at risk for readmission.

Overview of shorthand medical glossary (OMG) study

BACKGROUND

Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable.

AIM

We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries.

METHODS

Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff.

RESULTS

The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary.

CONCLUSION

Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.

A comparison of discharge strategies after chemotherapy completion in pediatric patients with acute myeloid leukemia: a report from the Children's Oncology Group

While most children receive acute myeloid leukemia (AML) chemotherapy as inpatients, there is variability in timing of discharge after chemotherapy completion. This study compared treatment-related morbidity, mortality and cumulative hospitalization in children with AML who were discharged after chemotherapy completion (early discharge) and those who remained hospitalized. Chart abstraction data for 153 early discharge-eligible patients enrolled on a Children's Oncology Group trial were compared by discharge strategy. Targeted toxicities included viridans group streptococcal (VGS) bacteremia, hypoxia and hypotension. Early discharge occurred in 11% of courses post-Induction I. Re-admission occurred in 80-100%, but median hospital stay was 7 days shorter. Patients discharged early had higher rates of VGS (adjusted risk ratio (aRR) = 1.67, 95% CI = 1.11-2.51), hypoxia (aRR = 1.92, 95% CI = 1.06-3.48) and hypotension (aRR = 4.36, 95% CI = 2.01-9.46), but there was no difference in mortality. As pressure increases to shorten hospitalizations, these results have important implications for determining discharge practices in pediatric AML.

Engaging stakeholders to design a comparative effectiveness trial in children with uncontrolled asthma

AIM

To present the methods and outcomes of stakeholder engagement in the development of interventions for children presenting to the emergency department (ED) for uncontrolled asthma.

METHODS

We engaged stakeholders (caregivers, physicians, nurses, administrators) from six EDs in a three-phase process to: define design requirements; prototype and refine; and evaluate.

RESULTS

Interviews among 28 stakeholders yielded themes regarding in-home asthma management practices and ED discharge experiences. Quantitative and qualitative evaluation showed strong preference for the new discharge tool over current tools.

CONCLUSION

Engaging end-users in contextual inquiry resulted in CAPE (CHICAGO Action Plan after ED discharge), a new stakeholder-balanced discharge tool, which is being tested in a multicenter comparative effectiveness trial.

Seeking support after hospitalisation for injury: a nested qualitative study of the role of primary care

BACKGROUND

In the UK, studies suggest that the transition from hospital to home after an injury can be a difficult time and many patients report feeling inadequately prepared. Patients often use primary care services after hospital discharge. These consultations provide opportunities to consider problems that patients experience and to facilitate recovery. Little is known, however, about how patients and service providers view care after hospital discharge and the role played by primary care services, specifically GPs.

AIM

To identify good practice and unmet needs in respect of post-discharge support for injured patients.

DESIGN AND SETTING

Qualitative study using semi-structured interviews at four sites (Bristol, Leicester/Loughborough, Nottingham, and Surrey).

METHOD

Qualitative interviews with 40 service providers and 45 hospitalised injured patients.

RESULTS

Although there were examples of well-managed hospital discharges, many patients felt they were not provided with the information they needed about their injury, what to expect in terms of recovery, pain control, return to work, psychological problems, and services to help meet their needs. They also described difficulty accessing services such as physiotherapy or counselling. Service providers identified problems with communication between secondary and primary care, lack of access to physiotherapy, poor communication about other services that may help patients, GP service and resource constraints, and difficulties in providing information to patients concerning likely prognosis.

CONCLUSION

Discharge from hospital after an injury can be problematic for patients. Changes in both secondary and primary care are required to resolve this problem.

Research in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: a review of the literature

AIM

To examine the literature on the impact of the discharge experience of patients with dementia and their continuity of care.

METHODS

Peer-reviewed and grey literature published in the English language between 1995 and 2014 were systematically searched using Medline, CINAHL, PubMed, PsycINFO and Cochrane library databases, using a combination of the search terms Dementia, Caregivers, Integrated Health Care Systems, Managed Care, Patient Discharge. Also reviewed were Department of Health and Ageing and Alzheimer's Australia research reports between 2000 and 2014.

RESULTS

The review found a wide range of studies that raise concerns in relation to the quality of care provided to people with dementia during hospital discharge and in transitional care.

CONCLUSION

Discharge planning and transitional care for patients with dementia are not adequate and are likely to lead to readmission and other poor health outcomes.

Predictors of home discharge among patients hospitalized for behavioural and psychological symptoms of dementia

BACKGROUND

The Japanese government recently announced the 'Five-Year Plan for Promotion of Measures Against Dementia (Orange Plan)' to promote people with dementia living in their communities. To achieve this, it is imperative that patients hospitalized with behavioural and psychological symptoms of dementia (BPSD) are helped to return to their own homes. The aim of the present study was to identify predictors of home discharge among patients hospitalized for BPSD.

METHODS

A single-centre chart review study was conducted on consecutive patients hospitalized from home between April 2006 and March 2011 for the treatment of BPSD. The frequency of discharge back to home was examined in relation to a patient's active behavioural problems and demographics at the time of admission. Diagnoses of dementia were made on the basis of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies.

RESULTS

In all, 391 patients were enrolled in the study. Of these patients, 163 (42%) returned home. Multiple logistic regression analysis identified high Mini-Mental State Examination and Nishimura-style senile activities of daily living scores as significant independent predictors of home discharge. In contrast, living alone and manifestation of aggressiveness at the time of admission were negatively associated with home discharge.

CONCLUSIONS

Few patients hospitalized for BPSD are discharged home, and this number is affected by a patient's clinical and demographic characteristics at the time of admission. These findings should be considered in designing and implementing optimal management and care strategies for patients with BPSD.

Evaluation of a New Zealand program to improve transition of care for older high risk adults

Transition interventions aim to improve care and reduce hospital readmissions but evaluations of these interventions have reported inconsistent results. We report on the evaluation of an intervention implemented in Auckland, New Zealand. Participants were people over the age of 65 who had an acute medical admission and were at high risk of readmission. The intervention included an improved discharge process and nurse telephone follow-up soon after discharge. Outcomes were 28 day readmission rates and emergency attendances. The study is observational, using both interrupted times series and regression discontinuity designs. 5239 patients were treated over a one year period. There was no change in readmission rates or ED attendances or secondary outcomes. Not all patients received all components of the intervention. This transition intervention was not successful. Possible reasons for this and implications are discussed. Although non-experimental methods were used, we believe the results are robust.

Impact of increasing overnight intensive care unit registrar staffing on duration of intubation of elective cardiac surgery patients

It is unclear whether increases to overnight junior medical staffing levels can improve ICU patient outcomes. We conducted a retrospective cohort study before and after the introduction of a third overnight ICU registrar at a 24-bed metropolitan ICU in February 2012. We hypothesised that this change would be associated with decreased intubation time for elective cardiac surgery patients and an increase in the proportion of these patients being extubated during the overnight period. All elective cardiac surgery patients were included from two temporally matched six-month periods (May to October) in 2011 and 2012. The primary outcome was median duration of intubation, and the secondary outcome was proportion of patients extubated during the 'overnight' period (2200 to 0700). A total of 142 and 188 patients were included in the control and intervention cohorts, respectively. Median (IQR) intubation time was 8.7 (6.6 to 14.5) hours in the control cohort and 8.2 (6.0 to 13.4) hours in the intervention cohort, with no significant difference between groups (P=0.40). The proportion of elective cardiac surgery patients extubated during the overnight period was similar, 54.2% in the control group compared to 50.0% in intervention group (P=0.45). In our unit, increasing overnight ICU registrar staffing levels was not associated with a significant reduction in duration of intubation for elective cardiac surgery patients or a reduction in the proportion of these patients extubated overnight. This is likely due to factors other than medical staffing levels influencing timing of extubation of these patients.

The effectiveness of family-centered transition processes from hospital settings to home: a review of the literature

BACKGROUND AND OBJECTIVES

The quality of care transitions is of growing concern because of a high incidence of postdischarge adverse events, poor communication with patients, and inadequate information transfer between providers. The objective of this study was to conduct a targeted literature review of studies examining the effectiveness of family-centered transition processes from hospital- and emergency department (ED)-to-home for improving patient health outcomes and health care utilization.

METHODS

We conducted an electronic search (2001-2012) of PubMed, CINAHL, Cochrane, PsycInfo, Embase, and Web of Science databases. Included were experimental studies of hospital and ED-to-home transition interventions in pediatric and adult populations meeting the following inclusion criteria: studies evaluating hospital or ED-to-home transition interventions, study interventions involving patients/families, studies measuring outcomes≤30 days after discharge, and US studies. Transition processes, principal outcome measures (patient health outcomes and health care utilization), and assessment time-frames were extracted for each study.

RESULTS

The search yielded 3458 articles, and 16 clinical trials met final inclusion criteria. Four studies evaluated pediatric ED-to-home transitions and indicated family-tailored discharge education was associated with better patient health outcomes. Remaining trials evaluating adult hospital-to-home transitions indicated a transition needs assessment or provision of an individualized transition record was associated with better patient health outcomes and reductions in health care utilization. The effectiveness of postdischarge telephone follow-up and/or home visits on health care utilization showed mixed results.

CONCLUSIONS

Patient-tailored discharge education is associated with improved patient health outcomes in pediatric ED patients. Effective transition processes identified in the adult literature may inform future quality improvement research regarding pediatric hospital-to-home transitions.