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Stricker LG, Running A, Lucas AH, McKenzie BA. Trauma Patient-Centered Discharge Plan Form: A Pilot Study. J Trauma Nurs 2024; 31:104-108. [PMID: 38484166 DOI: 10.1097/jtn.0000000000000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Comprehensive and multidisciplinary discharge planning can improve trauma patient throughput, decrease length of hospitalization, increase family and patient support, and expedite hospital discharge. OBJECTIVE This study aimed to assess the feasibility and acceptability of implementing a patient-centered discharge plan form for adult trauma patients. METHODS A single-center pilot study was conducted with adult trauma patients on a neurosurgical medical-surgical floor at a Level II trauma center in the Western United States from January to February 2023. The study had three phases: observation, pilot intervention, and follow-up. The key pilot intervention was the development of a standardized patient-centered discharge plan form, pilot tested by a trauma advanced practice provider and an inpatient discharge nurse. The primary outcome was the frequency of discharge orders being written before noon on the day of discharge. Qualitative and quantitative outcomes are reported. RESULTS The discharge form was used for eight patients during the pilot intervention phase; an advanced practice provider and an inpatient discharge nurse each completed the forms for four patients. Five of eight observed patients had discharge orders before noon; the incidence of orders before noon was slightly higher when the form was completed by the discharge nurse (three of four patients) than by the advanced practice provider (two of four patients). CONCLUSIONS The pilot study found that the patient-centered discharge plan form was feasible and acceptable to help improve the discharge process for trauma patients. Additional work to further refine the form's content and administration is warranted.
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Affiliation(s)
- Lisa G Stricker
- Author Affiliations: St. Vincent Healthcare, Billings, Montana (Drs Stricker and McKenzie); and Montana State University, Bozeman (Drs Running and Lucas)
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Falcetta MRR, Rados DV, Molina K, Oliveira D, Pozza CD, Schaan BD. Length of stay in the clinical wards in a hospital after introducing a multiprofessional discharge team: An effectiveness improvement report. J Hosp Med 2024; 19:101-107. [PMID: 38263757 DOI: 10.1002/jhm.13286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/19/2023] [Accepted: 01/09/2024] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Emergency overcrowding is a problem in hospitals worldwide. The expansion of wards has limitations. Hospital administrative leaders are constantly looking for opportunities to improve the efficiency of resource use. METHODS This is a care improvement study with a quasi-experimental design. We created a hospital discharge team (HDT) to solve the issues of prolonged hospital stays. The main interventions were active search and resolution of prolongation of stay and multi-disciplinary huddles. We developed strategies with different hospital units to expedite the processing of patients near discharge. Length of stay (LOS), morning hospital discharges, readmission rates, and bed usage were compared before (2018) and after (2019) HDT implementation. RESULTS There was a reduction in the mean LOS of 1.8 days (95% confidence interval [CI] -0.9 to -2.6; p < .001). The rate of hospital discharges before noon increased by 7.0% (95% CI 4%-11%; p < .001). The readmission rate was similar between 2018 and 2019 (+0.7%; 95% CI -0.1% to 1.9%; p = .358). We observed higher bed turnover, with 0.5 more hospitalizations per bed per month (95% CI 0.1-0.7; p = .01; mean of 3.7 ± 0.3 in 2018 and 4.1 ± 0.3 in 2019). CONCLUSION HDT brought benefits to our hospital, reducing the length of stay and increasing bed turnover. However, there is a need for a team focused on the project and support from managers to overcome resistance and integrate units until they are fully operational.
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Affiliation(s)
- Mariana R R Falcetta
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Dimitris V Rados
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Karine Molina
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Daiana Oliveira
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Caroline Dalla Pozza
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Beatriz D Schaan
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Safavi KC, Langle ACZ, Bravard MA, Stone C, Gil R, Strauss J, Britton O, Hillmann W, Dunn P. The Gap Between Daily Hospital Bed Supply and Demand: Design, Implementation, and Impact of Data-Driven Pre-Noon Discharge Targets. Jt Comm J Qual Patient Saf 2023; 49:181-188. [PMID: 36476954 DOI: 10.1016/j.jcjq.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospitals have sought to increase pre-noon discharges to improve capacity, although evidence is mixed on the impact of these initiatives. Past interventions have not quantified the daily gap between morning bed supply and demand. The authors quantified this gap and applied the pre-noon data to target a pre-noon discharge initiative. METHODS The study was conducted at a large hospital and included adult and pediatric medical/surgical wards. The researchers calculated the difference between the average cumulative bed requests and transfers in for each hour of the day in 2018, the year prior to the intervention. In 2019 an intervention on six adult general medical and two surgical wards was implemented. Eight intervention and 14 nonintervention wards were compared to determine the change in average cumulative pre-noon discharges. The change in average hospital length of stay (LOS) and 30-day readmissions was also calculated. RESULTS The average daily cumulative gap by noon between bed supply and demand across all general care wards was 32.1 beds (per ward average, 1.3 beds). On intervention wards, mean pre-noon discharges increased from 4.7 to 6.7 (p < 0.0000) compared with the nonintervention wards 14.0 vs. 14.6 (p = 0.19877). On intervention wards, average LOS decreased from 6.9 to 6.4 days (p < 0.001) and readmission rates were 14.3% vs 13.9% (p = 0.3490). CONCLUSION The gap between daily hospital bed supply and demand can be quantified and applied to create pre-noon discharge targets. In an intervention using these targets, researchers observed an increase in morning discharges, a decrease in LOS, and no significant change in readmissions.
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McFadden NR, Gosdin MM, Jurkovich GJ, Utter GH. Patient and clinician perceptions of the trauma and acute care surgery hospitalization discharge transition of care: a qualitative study. Trauma Surg Acute Care Open 2022; 7:e000800. [PMID: 35128068 PMCID: PMC8772453 DOI: 10.1136/tsaco-2021-000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Trauma and acute care surgery (TACS) patients face complex barriers associated with hospitalization discharge that hinder successful recovery. We sought to better understand the challenges in the discharge transition of care, which might suggest interventions that would optimize it. Methods We conducted a qualitative study of patient and clinician perceptions about the hospital discharge process at an urban level 1 trauma center. We performed semi-structured interviews that we recorded, transcribed, coded both deductively and inductively, and analyzed thematically. We enrolled patients and clinicians until we achieved data saturation. Results We interviewed 10 patients and 10 clinicians. Most patients (70%) were male, and the mean age was 57±16 years. Clinicians included attending surgeons, residents, nurse practitioners, nurses, and case managers. Three themes emerged. (1) Communication (patient-clinician and clinician-clinician): clinicians understood that the discharge process malfunctions when communication with patients is not clear. Many patients discussed confusion about their discharge plan. Clinicians lamented that poorly written discharge summaries are an inadequate means of communication between inpatient and outpatient clinicians. (2) Discharge teaching and written instructions: patients appreciated discharge teaching but found written discharge instructions to be overwhelming and unhelpful. Clinicians preferred spending more time teaching patients and understood that written instructions contain too much jargon. (3) Outpatient care coordination: patients and clinicians identified difficulties with coordinating ongoing outpatient care. Both identified the patient’s primary care physician and insurance coverage as important determinants of the outpatient experience. Conclusion TACS patients face numerous challenges at hospitalization discharge. Clinicians struggle to effectively help their patients with this stressful transition. Future interventions should focus on improving communication with patients, active communication with a patient’s primary care physician, repurposing, and standardizing the discharge summary to serve primarily as a means of care coordination, and assisting the patient with navigating the transition. Level of evidence III—descriptive, exploratory study.
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Affiliation(s)
- Nikia R McFadden
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis, Davis, California, USA
| | - Melissa M Gosdin
- Center for Healthcare Policy and Research, University of California Davis, Davis, California, USA
| | - Gregory J Jurkovich
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis, Davis, California, USA
- Department of Surgery Outcomes Research Group, University of California Davis, Davis, California, USA
| | - Garth H Utter
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis, Davis, California, USA
- Center for Healthcare Policy and Research, University of California Davis, Davis, California, USA
- Department of Surgery Outcomes Research Group, University of California Davis, Davis, California, USA
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Stocker B, Weiss HK, Weingarten N, Engelhardt KE, Engoren M, Posluszny J. Challenges in Predicting Discharge Disposition for Trauma and Emergency General Surgery Patients. J Surg Res 2021; 265:278-288. [PMID: 33964638 DOI: 10.1016/j.jss.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Changes in discharge disposition and delays in discharge negatively impact the patient and hospital system. Our objectives were1 to determine the accuracy with which trauma and emergency general surgery (TEGS) providers could predict the discharge disposition for patients and2 determine the factors associated with incorrect predictions. METHODS Discharge dispositions and barriers to discharge for 200 TEGS patients were predicted individually by members of the multidisciplinary TEGS team within 24 h of patient admission. Univariate analyses and multivariable logistic least absolute shrinkage and selection operator regressions determined the associations between patient characteristics and correct predictions. RESULTS A total of 1,498 predictions of discharge disposition were made by the multidisciplinary TEGS team for 200 TEGS patients. Providers correctly predicted 74% of discharge dispositions. Prediction accuracy was not associated with clinical experience or job title. Incorrect predictions were independently associated with older age (OR 0.98; P < 0.001), trauma admission as compared to emergency general surgery (OR 0.33; P < 0.001), higher Injury Severity Scores (OR 0.96; P < 0.001), longer lengths of stay (OR 0.90; P < 0.001), frailty (OR 0.43; P = 0.001), ICU admission (OR 0.54; P < 0.001), and higher Acute Physiology and Chronic Health Evaluation II scores (OR 0.94; P = 0.006). CONCLUSION The TEGS team can accurately predict the majority of discharge dispositions. Patients with risk factors for unpredictable dispositions should be flagged to better allocate appropriate resources and more intensively plan their discharges.
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Affiliation(s)
- Benjamin Stocker
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Hannah K Weiss
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noah Weingarten
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kathryn E Engelhardt
- Department of Surgery, Medical University of South Carolina, Charleston, South California
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Joseph Posluszny
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Kher S, Haas M, Schelling K, Wright S, Allison H, Poutsiaka DD, Roberts KE, Chang H, Salem DN, Kopelman R, Freund KM. Late-afternoon communication and patient planning (CAPP) rounds: an intervention to allow early patient discharges. Hosp Pract (1995) 2020; 49:56-61. [PMID: 32819172 DOI: 10.1080/21548331.2020.1814042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO). METHODS We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention. PROGRAM EVALUATION Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences. RESULTS Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time. CONCLUSION Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.
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Affiliation(s)
- Sucharita Kher
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Mark Haas
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA
| | - Kimberly Schelling
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Seth Wright
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Harmony Allison
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Debra D Poutsiaka
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Kari E Roberts
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Hong Chang
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center , Boston, MA, USA.,Clinical and Translational Science Institute, Tufts Medical Center , Boston, MA, USA
| | - Deeb N Salem
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Richard Kopelman
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA
| | - Karen M Freund
- Department of Medicine, Tufts Medical Center , Boston, Massachusetts, USA.,Tufts University School of Medicine , Boston, Massachusetts, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center , Boston, MA, USA
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Khorgami Z, Ewing KL, Mushtaq N, Chow GS, Howard CA. Predictors of discharge destination in patients with major traumatic injury: Analysis of Oklahoma Trauma Registry. Am J Surg 2019; 218:496-500. [DOI: 10.1016/j.amjsurg.2018.11.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 01/23/2023]
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Downie S, Joss J, Sripada S. A prospective cohort study investigating the use of a surgical planning tool to improve patient fasting times in orthopaedic trauma. Surgeon 2018; 17:80-87. [PMID: 29929769 DOI: 10.1016/j.surge.2018.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/24/2018] [Accepted: 05/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To improve surgical planning and reduce fasting times with a tool designed to predict average surgical times for the commonest orthopaedic trauma operations. METHODS A prospective cohort study comprising two 2-week periods before and after introduction of a surgical planning tool. The tool was used in the post-intervention group to predict surgical times for each patient and the predicted end-time for each list. The study was conducted in a UK trauma unit with consecutive orthopaedic trauma patients listed for surgery with no exclusions. INTERVENTION A surgical planning tool was generated by analysing 5146 electronic records for trauma procedure times. Average surgical times for the commonest 20 procedures were generated with 95% confidence intervals. The primary outcome measure was number of patients fasted for a single day. The secondary outcome measures were the day of surgery and total fast times for food and fluids. RESULTS After introduction of the planning tool, patients were more likely to fast for only one day (65% 46/71 vs 53% 40/75, p < 0.05). Day of surgery food fast was significantly lower with use of the surgical planning tool (13:11 h to 11:44 h, p < 0.05). Fast times were lower for patients with hip fractures after the intervention, with a reduction in day of surgery fast from 8:25 h to 4:28 h (p < 0.05) and a total fluid fast of 13:00 h to 4:31 h (p < 0.001). CONCLUSIONS Introduction of a surgical planning tool was associated with a decrease in fasting times for orthopaedic trauma patients with no patient cancelled for not being adequately fasted.
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Affiliation(s)
- Samantha Downie
- Department of Trauma & Orthopaedics, Ninewells Hospital & Medical School, Dundee, United Kingdom.
| | - Judith Joss
- Department of Intensive Care Medicine & Anaesthesia, Ninewells Hospital & Medical School, Dundee, United Kingdom.
| | - Sankar Sripada
- Department of Trauma & Orthopaedics, Ninewells Hospital & Medical School, Dundee, United Kingdom.
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