Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review

Quality of care transition, patient safety incidents, and patients' health status: a structural equation model on the complexity of the discharge process

BACKGROUND

The transition of patients between care contexts poses patient safety risks. Discharges to home from inpatient care can be associated with adverse patient outcomes. Quality in discharge processes is essential in ensuring safe transitions for patients. Current evidence relies on bivariate analyses and neglects contextual factors such as treatment and patient characteristics and the interactions of potential outcomes. This study aimed to investigate the associations between the quality and safety of the discharge process, patient safety incidents, and health-related outcomes after discharge, considering the treatments' and patients' contextual factors in one comprehensive model.

METHODS

Patients at least 18 years old and discharged home after at least three days of inpatient treatment received a self-report questionnaire. A total of N = 825 patients participated. The assessment contained items to assess the quality and safety of the discharge process from the patient's perspective with the care transitions measure (CTM), a self-report on the incidence of unplanned readmissions and medication complications, health status, and sociodemographic and treatment-related characteristics. Statistical analyses included structural equation modeling (SEM) and additional analyses using logistic regressions.

RESULTS

Higher quality of care transition was related to a lower incidence of medication complications (B = -0.35, p < 0.01) and better health status (B = 0.74, p < 0.001), but not with lower incidence of readmissions (B = -0.01, p = 0.39). These effects were controlled for the influences of various sociodemographic and treatment-related characteristics in SEM. Additional analyses showed that these associations were only constant when all subscales of the CTM were included.

CONCLUSIONS

Quality and safety in the discharge process are critical to safe patient transitions to home care. This study contributes to a better understanding of the complex discharge process by applying a model in which various contextual factors and interactions were considered. The findings revealed that high quality discharge processes are associated with a lower likelihood of patient safety incidents and better health status at home even, when sociodemographic and treatment-related characteristics are taken into account. This study supports the call for developing individualized, patient-centered discharge processes to strengthen patient safety in care transitions.

[Closing care gaps after hospitalization: Study results [intersec-CM] on discharge and transfer management according to sect. 39 SGB V for people with cognitive impairments associated with dementia]

In Germany, there are 1.8 million people currently living with dementia, and the trend is rising. In particular, the health system at the transition from hospital to outpatient care is facing major challenges given the high increase in a difficult patient clientele. Legal efforts have been undertaken (sect. 39a of the Fifth Social Code Book [SGB V]) to close the care gaps in the discharge and transfer process. This article aims to provide an overview of the documentation process of the discharge and transfer management for people with cognitive impairments in everyday clinical practice according to SGB V sect. 39 para. 1a after the Discharge Management Act came into force. Furthermore, the manuscript answers the research question "How is the statutory discharge management of people with cognitive impairments (MmkB) aged 65 and over documented" and highlights further characteristics of the discharge documentation for MmkB starting with the transition from the inpatient setting to other care settings. In order to answer the research question(s), a qualitative content analysis of all discharge documents available at the time of discharge was carried out as part of the intervention study on cross-sector care management to support cognitively impaired people during and after a hospital stay [intersec-CM], which was funded by the Federal Ministry of Education and Research. The results of the analysis show that, despite legal efforts, there are currently no standardized, unified processes of discharge management for people with cognitive impairments that can be traced in writing. However, departments with a large proportion of vulnerable patient groups were able to offer valuable insights: for example, their discharge documents included a short social history. Further evidence-based research and development in the domain of discharge management for people with cognitive impairments remains essential.

Barriers and Facilitators of a Community-Based, Slow-Stream Rehabilitation, Hospital-to-Home Transition Program for Older Adults: Perspectives of a Multidisciplinary Care Team

The purpose of this study was to examine the perspectives of support staff, health care professionals, and care coordinators working in or referring to a community-based, slow-stream rehabilitation, hospital-to-home transition program regarding gaps in services, and barriers and facilitators related to implementation and functioning of the program. This was a qualitative descriptive study. Recruitment was conducted through purposive sampling, and 23 individuals participated in a focus groups or individual semi-structured interview. Transcripts were analyzed by six researchers using inductive thematic analysis. Themes that emerged were organized based on a socio-ecological framework. Themes were categorized as: (1) macro level, meaning gaps while waiting for program, limited program capacity, and gaps in service post-program completion; (2) meso level, meaning lack of knowledge and awareness of the program, lack of specific referral process and procedures, lack of specific eligibility criteria, and need for enhanced communication among care settings; or (3) micro level, meaning services provided, program participant benefits, person-centred communication, program structure constraints, need for use of outcome measures, and follow-up or lack of follow-up. Implementation of seamless patient information sharing, documentation, use of specific referral criteria, and use of standardized outcome measures may reduce the number of unsuitable referrals and provide useful information for referral and program staff.

Understanding data collection strategies for the ethical inclusion of older adults with disabilities in transitional care research: A scoping review protocol

INTRODUCTION

A growing body of evidence suggests that older adults are particularly vulnerable to poor care as they transition across care environments. Thus, they require transitional care services as they transition across healthcare settings. To help make intervention research meaningful to the older adults the intervention aims to serve, many researchers aim to study their experiences, by actively involving them in research processes. However, collecting data from older adults with various forms of disability often assumes that the research methods selected are appropriate for them. This scoping review will map the evidence on research methods to collect data from older adults with disabilities within the transitional care literature.

METHODS

The proposed scoping review follows the framework originally described by the Joanna Briggs Institute (JBI) Manual: (1) developing a search strategy, (2) evidence screening and selection, (3) data extraction; and (4) analysis. We will include studies identified through a comprehensive search of peer-reviewed and empirical literature reporting on research methods used to elicit the experiences of older adults with disabilities in transitional care interventions. In addition, we will search the reference lists of included studies. The findings of this review will be narratively synthesized. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews will guide the reporting of the methods and results.

DISCUSSION

The overarching goal of this study is to develop strategies to assist the research community in increasing the inclusion of older adults with disabilities in transitional care research. The findings of this review will highlight recommendations for research to inform data collection within future intervention research for older adults with disabilities. Study findings will be disseminated via a publication and presentations.

The Path to Sustainable Healthcare: Implementing Care Transition Teams to Mitigate Hospital Readmissions and Improve Patient Outcomes

Introduction Hospital readmissions within 30 days suggest care quality issues and increased mortality risks. They result from ineffective initial treatment, poor discharge planning, and inadequate post-acute care. These high readmission rates harm patient outcomes and financially strain healthcare institutions, inviting penalties and discouraging potential patients. Enhancing inpatient care, care transitions, and case management is crucial to lowering readmissions. Our research underscores the role of care transition teams in reducing readmissions and financial stress in hospitals. By consistently applying transition strategies and focusing on high-quality care, we can improve patient outcomes and ensure hospital success in the long run. Methods This two-phase study investigated readmission rates and risk factors in a community hospital from May 2017 to November 2022. Phase 1 determined a baseline readmission rate and identified individual risk factors using logistic regression. In phase 2, a care transition team addressed these factors by providing post-discharge patient support through phone calls and assessing social determinants of health (SDOH). Readmission data from the intervention period was compared to baseline data using statistical tests. Data, including demographics, medical conditions, and comorbidities, were collected via electronic medical records and the International Classification of Diseases (ICD-10 codes). The study focused on patients aged 20-80 with readmissions within 30 days. Exclusions were made to minimize confounding effects from unmeasured comorbidities and ensure an accurate representation of factors affecting readmissions. Results In the study's initial phase, 74,153 patients participated, with an 18% mean readmission rate. Women accounted for 46% of readmissions, and the white population had the highest rate (49%). The 40-59 age group showed a higher readmission rate than other age groups, and certain health factors were identified as risk factors for 30-day readmission. In the subsequent phase, a care transition team intervened with high-risk groups using an SDOH questionnaire. They contacted 432 patients, resulting in a reduced overall readmission rate of 9%. The 60-79 age group and the Hispanic population experienced higher readmission rates, and the previously identified health factors remained significant risk factors. Conclusion This study emphasizes the crucial role of care transition teams in reducing hospital readmission rates and easing the financial strain on healthcare institutions. By identifying and addressing individual risk factors, the care transition team effectively lowered the overall readmission rate from 18% to 9%. Continually implementing transition strategies and prioritizing high-quality care focused on minimizing readmissions are essential for improving patient outcomes and long-term hospital success. Healthcare providers should consider utilizing care transition teams and social determinants of health assessments to better understand and manage risk factors and tailor post-discharge support for patients at higher risk of readmission.

Implementing a discharge process for patients undergoing elective surgery: Rapid review

BACKGROUND

Hospital discharge is a 'vulnerable stage' in care. A delayed, inappropriate or poorly planned discharge increases hazards and costs, inhibiting recovery, and often leading to unplanned readmission. New discharge processes could boost practice, reduce the length of stay, and, consequently, reduce costs and improve patients' quality of life.

AIM

To identify technology based interventions that have been implemented to facilitate a safe and timely discharge procedure after elective surgery, and to describe implementation barriers and facilitators and patient satisfaction.

METHOD

This rapid review followed a restricted systematic review framework, searching Medline, EMBASE, CINAHL, PsychINFO, and ClinicalTrials.gov. for relevant studies published from 2015 to 2021 in English.

RESULTS

Eleven studies were included. Most interventions were machine-learning-based, and only one study reported patient involvement. Effective leadership, team work and communication were stated as implementation facilitators. The main barriers to implementation were: lack of support from leaders, poor clinical documentation, resistance to change, and financial and logistical concerns. None of the studies evaluated patient satisfaction.

CONCLUSIONS

Findings highlight factors that support the implementation of technology based interventions aimed at a safe and timely discharge process following elective surgery. Nurses play an important role in the provision of information, and in the development and implementation of discharge processes.

Hospital Admission and Discharge: Lessons Learned from a Large Programme in Southwest Germany

Introduction

In the context of a GP-based care programme, we implemented an admission, discharge and follow-up programme.

Description

The VESPEERA programme consists of three sets of components: pre-admission interventions, in-hospital interventions and post-discharge interventions. It was aimed at all patients with a hospital stay participating in the GP-based care programme and was implemented in 7 hospitals and 72 general practices in southwest Germany using a range of strategies. Its' effectiveness was evaluated using readmissions within 90 days after discharge as primary outcome. Questionnaires with staff were used to explore the implementation process.

Discussion

A statistically significant effect was not found, but the effect size was similar to other interventions. Intervention fidelity was low and contextual factors affecting the implementation, amongst others, were available resources, external requirements such as legal regulations and networking between care providers. Lessons learned were derived that can aid to inform future political or scientific initiatives.

Conclusion

Structured information transfer at hospital admission and discharge makes sense but the added value in the context of a GP-based programme seems modest. Primary care teams should be involved in pre- and post-hospital care.

Adherence to oral anti-cancer therapies in older patients is similar to that of younger patients

Introduction

The use of oral anti-cancer therapies is becoming increasingly common in the management of cancers, raising the question of adherence. The objective of this study was to assess adherence to oral anti-cancer therapies, as well as the impact of various factors that may influence it.

Methods

Patients starting oral chemotherapy (tyrosine kinase inhibitor or cytotoxic) were followed up for 3 months using a medication diary, which was given to the patient by the pharmacist during a multidisciplinary consultation. Adherence was assessed using the diary, as well as by counting the tablets they brought back.

Results

One hundred and fifty patients were included in the study. The main oral chemotherapy agents prescribed were palbociclib (23.3%), everolimus (18.7%), and capecitabine (13.3%). The adherence at the end of the 3 months, by means of dose intensity (i.e. percent of the dose prescribed that has been taken), was 95.5%. No significant difference in adherence was found based on age, sex, family circumstances, health status, co-medication, type of oral therapy, tumor location, number of previous treatment lines, or presence of toxicity. The main reasons for non-adherence were forgetting (50%) and toxicity (21%). Fifty-seven patients prematurely discontinued the study: 40.3% for toxicity and 36.8% for disease progression.

Conclusion

Adherence in this study is high in comparison to literature, which can be explained by close multidisciplinary follow-up. Moreover, no significant difference was observed between younger and older patients.

Analysis of Readmissions in a Mobile Integrated Health Transitional Care Program Using Root Cause Analysis and Common Cause Analysis

ABSTRACT

Mobile integrated health and community paramedicine (MIH-CP) programs are gaining popularity in the United States as a strategy to address the barriers to healthcare access and appropriate utilization. After one year of operation, leadership of Baltimore City's MIH-CP program was interested in understanding the circumstances surrounding readmission for enrolled patients and to incorporate quality improvement tools to direct program development. Retrospective chart review was performed to determine preventable versus unpreventable readmissions with a hypothesis that deficits in social determinants of health would play a more significant role in preventable readmissions. In the studied population, at least one root cause that can be considered a social determinant of health was present in 75.8% of preventable readmissions versus only 15.2% of unpreventable readmissions. Root Cause Analysis highlighted health literacy, functional status, and behavioral health issues among the root causes that most heavily influence preventable readmissions. Common Cause Analysis results suggest our MIH-CP program should focus its resources on mitigating poor health literacy and functional status. This project's findings successfully directed leadership of the city's MIH-CP program to modify program processes and advocate for the use of these quality improvement tools for other MIH-CP programs.

The Influence of Nurse Education Level on Hospital Readmissions-A Cost-Effectiveness Analysis

Background: Readmissions are adverse, costly, and potentially preventable. The study aimed to evaluate the cost-effectiveness of reducing readmissions resulting from missed care, depending on the level of education of nurses, from the perspective of the service provider. Methods: We calculated missed care resulting in additional readmissions based on the longitudinal study conducted between 2012 and 2014, as well as readmissions that could have been potentially prevented by adding a 10% increase in hours of nursing care provided by BSN/MSc nurses for 2014. The cost-effectiveness analysis (CEA) was performed to calculate the cost-effectiveness of preventing one hospitalization in non-surgical and surgical wards by increasing the number of nursing hours provided by BSN/MSc nurses. Cost−benefit analysis (CBA) was performed, and the CBR (cost−benefit ratio) and BCR (benefit−cost ratio) were calculated. Results: Increasing the number of hours of nursing care (RN) by 10% decreased the chance for an unplanned readmission by 11%; (OR = 0.89; 95% CI: 0.78−1.01; p = 0.08) in non-surgical wards and 43% (OR = 0.57; 95% CI: 0.49−0.67; p < 0.001) in surgical wards. In non-surgical wards, the number of readmissions that were preventable with extra hours provided by BSN/MSc nurses was 52, and the cost-effectiveness ratio (CER) was USD 226.1. The number of preventable readmissions in surgical wards was 172, and the CER was USD 54.96. In non-surgical wards, the CBR was USD 0.07, while the BCR was USD 1.4. In surgical wards, the CBR was USD 0.02, and the BCR was USD 4.4. Conclusions: The results of these studies broaden the understanding of the relationship among nursing education, patient readmission, and the economic outcomes of hospital care. According to the authors, the proposed intervention has an economic justification. Hence, the authors recommend it for approval by the service provider.

Effect of health information technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: a systematic review

OBJECTIVE

To systematically synthesize and appraise the evidence on the effectiveness of health information technology (HIT)-based discharge care transition interventions (CTIs) on readmissions and emergency room visits.

MATERIALS AND METHODS

We conducted a systematic search on multiple databases (MEDLINE, CINAHL, EMBASE, and CENTRAL) on June 29, 2020, targeting readmissions and emergency room visits. Prospective studies evaluating HIT-based CTIs published as original research articles in English language peer-reviewed journals were eligible for inclusion. Outcomes were pooled for narrative analysis.

RESULTS

Eleven studies were included for review. Most studies (n = 6) were non-RCTs. Several studies (n = 9) assessed bridging interventions comprised of at least 1 pre- and 1 post-discharge component. The narrative analysis found improvements in patient experience and perceptions of discharge care.

DISCUSSION

Given the statistical and clinical heterogeneity among studies, we could not ascertain the cumulative effect of CTIs on clinical outcomes. Nevertheless, we found gaps in current research and its implications for future work, including the need for a HIT-based care transition model for guiding theory-driven design and evaluation of HIT-based discharge CTIs.

CONCLUSIONS

We appraised and aggregated empirical evidence on the cumulative effectiveness of HIT-based interventions to support discharge transitions from hospital to home, and we highlighted the implications for evidence-based practice and informatics research.

Discharge interventions from inpatient child and adolescent mental health care: a scoping review

The post-discharge period is an extremely vulnerable period for patients, particularly for those discharged from inpatient children and adolescent mental health services (CAMHS). Poor discharge practices and discontinuity of care can put children and youth at heightened risk for readmission, among other adverse outcomes. However, there is limited understanding of the structure and effectiveness of interventions to facilitate discharges from CAMHS. As such, a scoping review was conducted to identify the literature on discharge interventions. This scoping review aimed to describe key components, designs, and outcomes of existing discharge interventions from CAMHS. Nineteen documents were included in the final review. Discharge interventions were extracted and summarized for pre-discharge, post-discharge, and bridging elements. Results of this scoping review found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support. Reported outcomes of discharge interventions were also extracted and included positive patient and caregiver satisfaction, improved patient health outcomes, and increased cost effectiveness. Literature on discharge interventions from inpatient CAMHS, while variable in structure, consistently underscore the role of such interventions in minimizing patient and family vulnerability post-discharge. However, findings are limited by inadequate reporting and heterogeneity across studies. There is a need for further research into the design, implementation, and evaluation of interventions to support successful discharges from inpatient child and adolescent mental health care.

Direct phone communication to primary care physician to plan discharge from hospital: feasibility and benefits

BACKGROUND

The discharge summary is the main vector of communication at the time of hospital discharge, but it is known to be insufficient. Direct phone contact between hospitalist and primary care physician (PCP) at discharge could ensure rapid transmission of information, improve patient safety and promote interprofessional collaboration. The objective of this study was to evaluate the feasibility and benefit of a phone call from hospitalist to PCP to plan discharge.

METHODS

This study was a prospective, single-center, cross-sectional observational study. It took place in an acute medicine unit of a French university hospital. The hospitalist had to contact the PCP by telephone within 72 h prior discharge, making a maximum of 3 call attempts. The primary endpoint was the proportion of patients whose primary care physician could be reached by telephone at the time of discharge. The other criteria were the physicians' opinions on the benefits of this contact and its effect on readmission rates.

RESULTS

275 patients were eligible. 8 hospitalists and 130 PCPs gave their opinion. Calls attempts were made for 71% of eligible patients. Call attempts resulted in successful contact with the PCP 157 times, representing 80% of call attempts and 57% of eligible patients. The average call completion rate was 47%. The telephone contact was perceived by hospitalist as useful and providing security. The PCPs were satisfied and wanted this intervention to become systematic. Telephone contact did not reduce the readmission rate.

CONCLUSIONS

Despite the implementation of a standardized process, the feasibility of the intervention was modest. The main obstacle was hospitalists lacking time and facing difficulties in reaching the PCPs. However, physicians showed desire to communicate directly by telephone at the time of discharge.

TRIAL REGISTRATION

French C.N.I.L. registration number 2108852. Registration date October 12, 2017.

The effect of a mobile integrated health program on health care cost and utilization

OBJECTIVE

To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges.

DATA SOURCES

Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019.

STUDY DESIGN

We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge.

DATA COLLECTION

Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period.

PRINCIPAL FINDINGS

The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio = 1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio = 1.78, 95% CI = [1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes.

CONCLUSIONS

We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

The effect of discharge planning on length of stay and readmission rates of older adults in acute hospitals: A systematic review and meta-analysis of systematic reviews

AIM

To examine the effectiveness of discharge planning on length of stay and readmission rates among older adults in acute hospitals.

BACKGROUND

Discharge planning takes place in all acute hospital settings in many forms. However, it is unclear how it contributes to reducing patient length of stay in hospital and readmission rates.

METHODS

Seven systematic reviews were identified and examined. All of the systematic reviews explored the impact of discharge planning on length of stay and readmission rates.

RESULTS

A limited meta-analysis of the results in relation to length of stay indicates positive finding for discharge planning as an intervention (MD = -0.71(95% CI -1.05,-0.37; p = .0001)). However, further analysis of the broader findings in relation to length of stay indicates inconclusive or mixed results. In relation to readmission rates both meta-analysis and narrative analysis point to a reduced risk for older people where discharge planning has taken place (RR = 0.78 (95% CI: 0.72, 0.84; p = .00001)). The ability to synthesize results however is severely hampered by the diversity of approaches to research in this area.

IMPLICATIONS FOR NURSING MANAGEMENT

It is unclear what impact discharge planning has on length of stay of older people. Indeed, while nurse mangers will be interested in gauging this impact on throughput and patient flow, it is questionable if length of stay is the correct outcome to measure when studying discharge planning as good discharge planning may increase length of stay. Readmission rates may be a more appropriate outcome measure but standardization of approach needs to be considered in this regard. This would assist nurse managers in assessing the impact of discharge planning processes.

Towards living guidelines on cardiorenal outcomes in diabetes: A pilot project of the Taskforce of the Guideline Workshop 2020

In June 2020, the Taskforce of the Guideline Workshop 2019 convened via teleconferencing to initiate a pilot project that demonstrates the various processes and considerations involved in developing high-quality, evidence-based clinical practice guidelines for the medical management of individuals with type 2 diabetes (T2D) and its associated comorbidities, including cardiovascular disease (CVD) and chronic kidney disease (CKD). The goal of the pilot project was to create evidence-based guidelines for use of sodium-glucose transport protein 2 inhibitors (SGLT2-I) when managing very high risk T2D patients, evidenced by the presence of both CVD and CKD. For this purpose the Taskforce represented a guideline panel and made use of synthesized evidence from an ongoing BMJ Rapid Recommendations project on SGLT2-I and GLP-1 receptor agonists. Results from the Taskforce pilot project demonstrated the value, feasibility and utility of using a step-wise approach to identifying and grading evidence and then developing actionable recommendations for utilizing SGLT2-I in this at-risk T2D population. This report describes the various steps involved in the process and explains how it can be utilized to rapidly develop recommendations in a format that is easy to use and can be quickly updated as new evidence becomes available, also within the emerging concept of living guidelines.

How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study

INTRODUCTION

Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process and drive variations in patient outcomes. We sought to categorize contextual drivers that vary between high- and low-performing hospitals in older adult transition from hospitals to SNFs.

DESIGN

To identify contextual drivers, we used a rapid ethnographic approach with interviews and direct observations of hospital and SNF clinicians involved in discharging patients. We conducted thematic analysis to categorize contextual factors and compare differences in high- and low-performing sites.

SETTING AND PARTICIPANTS

We stratified hospitals on 30-day hospital readmission rates from SNFs and used convenience sampling to identify high- and low-performing sites and associated SNFs. The final sample included 4 hospitals (n = 2 high performing, n = 2 low performing) and affiliated SNFs (n = 5) with 148 hours of observations.

MEASURES

Central themes related to how contextual factors influence variations in high- and low-performing hospitals.

RESULTS

We identified 3 main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, the types of patients cared for at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients based on their needs instead of financial abilities. Third, at high-performing hospitals a more engaged staff in the transition process and building rapport with SNFs characterized smooth transitions from hospitals to SNFs.

CONCLUSIONS AND IMPLICATIONS

Contextual factors distinguish high- and low-performing hospitals in transitions to SNF and can be used to develop interventions to reduce adverse outcomes in transitions.

Development of salient medication reminders to facilitate information transfer during transition from inpatient to primary care: the Delphi process

OBJECTIVE

Transitional care is important to successful hospital discharge. Providing patients with a clear and concise summary of medication-related information can help improve outcomes, in particular, among older adults. The present study aimed to propose a framework for the development of salient medication reminders (SMR), which include drug-related risks and precautions, using the Delphi process.

DESIGN

Identification of potential SMR statements for 80% of medication types used by older adult patients discharged from geriatric medicine departments, followed by a Delphi survey and expert panel discussion.

SETTINGS

Medical and geriatric departments of public hospitals in Hong Kong.

PARTICIPANTS

A panel of 13 geriatric medical experts.

OUTCOME MEASURE

A Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) points, scoring item relevance, importance and clarity. The minimum of 70% consensus was required for each statement to be included.

RESULTS

The expert panel achieved consensus through the Delphi process on 80 statements for 44 medication entities. Subsequently, the SMR steering group endorsed the inclusion of these statements in the SMR to be disseminated among older adults at the time of discharge from geriatric medicine departments.

CONCLUSIONS

The Delphi process contributed to the development of SMR for older adult patients discharged from public hospitals in Hong Kong. Patient experience with and staff response to the SMR were assessed at four hospitals before implementation at all public hospitals.

Interventions to Improve Hospital Admission and Discharge Management: An Umbrella Review of Systematic Reviews

BACKGROUND

The aim of this umbrella review was to summarize the research evidence on programs to improve the transition between ambulatory and hospital care.

METHODS

The MEDLINE database and the Cochrane library were searched. Systematic reviews of randomized controlled trials published between January 2000 and September 2018 in English or German were included. Studies were eligible if an assessment or coordination intervention had been evaluated and if patients had been transferred between hospital (defined as internal medicine, surgery, or unspecified hospital setting) and home (defined as any permanent residence). Risk of bias was assessed using the AMSTAR criteria. Results are presented descriptively and in table format.

RESULTS

Thirty-nine systematic reviews comprising 492 different studies were included. More than half of these studies were conducted in the United States, the United Kingdom, Canada, and Australia. All studies evaluated strategies to improve discharge management (introduced after patients' arrival at the hospital); no study assessed strategies to improve admission management (initiated in primary care before patients' transition to hospital). The reviews included focused on a specific patient group, a specific intervention type, or a specific outcome. Overall, interventions focusing on elderly patients and high-intensity interventions seemed to be most effective. An overview of classifications of care transition strategies is provided.

CONCLUSIONS

Future research should focus on hospital admission management programs.

A pragmatic randomized controlled trial of a cardiac hospital-to-home transitional care program in a Singapore academic medical center

Background

Rehospitalizations are common in healthcare. They are costly for hospitals and patients and a substantial percentage are preventable, partly because hospital-to-community transitions are often unmanaged or poorly managed. In this study, we conducted a pragmatic randomized, controlled trial to evaluate the effectiveness of a new nurse–practitioner-led transitional care program called CareHub, piloted in Singapore’s National University Hospital.

Methods

Study population included all eligible cardiac patients admitted between July 2016 and November 2016. Patients were followed for six months post-discharge. Primary outcomes other than emergency department visits were all cardiac-related: number of readmissions, specialist visits, emergency department visits, and total days readmitted. Secondary outcomes: variables related to quality of life and transitional care. Regression analyses were used to estimate the intent-to-treat effect of CareHub and explore treatment heterogeneity.

Results

CareHub reduced the mean number of unplanned readmissions by 0.23 (a 39% reduction relative to control mean of 0.60 unplanned readmissions, p < 0.05), mean number of all readmissions by 0.20 (31% reduction relative to control mean of 0.63 readmissions, p = 0.10), mean number of total unplanned days in hospital by 2.2 (56% reduction relative to control mean of 4.0 days, p < 0.05), mean number of total days in hospital by 2.0 (42% reduction relative to control mean of 4.3 days, p < 0.10). Treatment effects varied by pre-admission health and socio-economic status.

Conclusion

A carefully designed protocolized cardiac hospital-to-home transition program can reduce resource utilization while improving quality of life.

Evaluation of the TRANSITION tool to improve communication during older patients' care transitions: Healthcare practitioners' perspectives

AIMS

To evaluate healthcare practitioners' perceptions of the feasibility and acceptability of a communication tool, entitled the TRANSITION tool, to communicate with older patients during transition from acute care to a community setting.

BACKGROUND

Transitional care for older patients is challenging due to their complex care needs and rapid care transitions. Research has identified effective models of transitional care. However, optimal communication between healthcare practitioners and older patients remains under-investigated.

DESIGN

Exploratory descriptive qualitative design.

METHODS

The methods are reported using the Consolidated Criteria for Reporting Qualitative Studies checklist. The setting comprised two acute medical wards in an urban hospital in Australia. Twenty-two nursing and allied healthcare practitioners used the TRANSITION tool to guide communication about transitional care with an older patient and then participated in an interview about their experience of using the tool. All data were thematically analysed.

FINDINGS

Healthcare practitioners reported their perceptions that the TRANSITION tool was feasible and acceptable, and that they perceived the tool supported them to know what to ask and to find out information regarding their patient's transitional care needs. Some ward-based nurses reported their perception that transitional care was not their role.

CONCLUSIONS

Findings emphasise transitional care as a continuing care process that requires effective communication between nurses and older patients in acute medical wards.

RELEVANCE TO CLINICAL PRACTICE

Given shorter lengths of stay, complex care needs and slow recovery, ward-based nurses are vital in communicating with older patients about their transitional care needs. The TRANSITION tool may support communication between ward-based nurses and older patients to improve assessment and planning. Implementation of the tool will require a planned strategy to facilitate translation of the tool into routine practice of ward-based nurses to support their roles during older patients' care transitions.

The Discharge Communication Study: research protocol for a mixed methods study to investigate and triangulate discharge communication experiences of patients, GPs, and hospital professionals, alongside a corresponding discharge letter sample

BACKGROUND

Discharge letters are crucial during care transitions from hospital to home. Research indicates a need for improvement to increase quality of care and decrease adverse outcomes. These letters are often sent from the hospital discharging physician to the referring clinician, typically the patient's General Practitioner (GP) in the UK, and patients may or may not be copied into them. Relatively little is known about the barriers and enablers to sending patients discharge letters. Hence, the aim of this study was to investigate from GP, hospital professional (HP) and patient perspectives how to improve processes of patients receiving letters and increase quality of discharge letters. The study has a particular focus on the impacts of receiving or not receiving letters on patient experiences and quality of care.

METHODS

The setting was a region in the West Midlands of England, UK. The research aimed to recruit a minimum of 30 GPs, 30 patients and 30 HPs in order to capture 90 experiences of discharge communication. Participating GPs initially screened and selected a range of recent discharge letters which they assessed to be successful and unsuccessful exemplars. These letters identified potential participants who were invited to take part: the HP letter writer, GP recipient and patient. Participant viewpoints are collected through interviews, focus groups and surveys and will be "matched" to the discharge letter sample, so forming multiple-perspective "quartet" cases. These "quartets" allow direct comparisons between different discharge experiences within the same communicative event. The methods for analysis draw on techniques from the fields of Applied Linguistics and Health Sciences, including: corpus linguistics; inferential statistics; content analysis.

DISCUSSION

This mixed-methods study is novel in attempting to triangulate views of patients, GPs and HPs in relation to specific discharge letters. Patient and practitioner involvement will inform design decisions and interpretation of findings. Recommendations for improving discharge letters and the process of patients receiving letters will be made, with the intention of informing guidelines on discharge communication. Ethics approval was granted in July 2017 by the UK Health Research Authority. Findings will be disseminated in peer-reviewed journals, reports and newsletters, and presentations.

Evaluation of Tailored Falls Education on Older Adults' Behavior Following Hospitalization

BACKGROUND

Older adults recently discharged from the hospital are known to be at risk of functional decline and falls. This study evaluated the effect of a tailored education program provided in the hospital on older adult engagement in fall prevention strategies within 6 months after hospital discharge.

METHODS

A process evaluation of a randomized controlled trial that aimed to improve older adult fall prevention behaviors after hospital discharge. Participants (n = 390) were aged 60 years and older with good cognitive function (greater than 7 of 10 Abbreviated Mental Test Score), discharged home from three hospital rehabilitation wards in Perth, Australia. The primary outcomes were engagement in fall prevention strategies, including assistance with daily activities, home modifications, and exercise. Data were analyzed using generalized linear modeling.

RESULTS

There were 76.4% (n = 292) of participants who completed the final interview (n = 149 intervention, n = 143 control). There were no significant differences between groups in engagement in fall prevention strategies, including receiving instrumental activity of daily living (IADL) assistance (adjusted odds ratio [AOR] = 1.3 [95% confidence interval {CI} = 0.7-2.1]; P = .3), completion of home modifications (AOR = 1.2 [95% CI = 0.7-1.9]; P = .4), and exercise (AOR = 1.3 [95% CI = 0.7-2.2]; P = .3). There was a high proportion of unmet ADL needs within both groups, and levels of participant dependency remained higher at 6 months compared to baseline levels at admission. The proportion of all participants who engaged in exercise following hospital discharge increased by 30%; however, the mean duration of exercise reduced from 3 hours per week at baseline to 1 hour per week at 6-month follow-up (SD = 1.12 hours per week).

CONCLUSION

Tailored education did not increase older adult engagement in fall prevention strategies after hospital discharge compared to usual care. Further research is required to evaluate older adults' capacity to change their behaviors once they return home from hospital, which may enable a safer recovery of their independence. J Am Geriatr Soc 67:2274-2281, 2019.

Safe handovers for every patient: an interrupted time series analysis to test the effect of a structured discharge bundle in Dutch hospitals

OBJECTIVE

Patient handovers are often delayed, patients are hardly involved in their discharge process and hospital-wide standardised discharge procedures are lacking. The aim of this study was to implement a structured discharge bundle and to test the effect on timeliness of medical and nursing handovers, length of hospital stay (LOS) and unplanned readmissions.

DESIGN

Interrupted time series with six preintervention and six postintervention data collection points (September 2015 to June 2017).

SETTING

Internal medicine and surgical wards PARTICIPANTS: Patients (≥18 years) admitted for more than 48 hours to surgical or internal medicine wards.

INTERVENTION

The Transfer Intervention Procedure (TIP), containing four elements: planning the discharge date within 48 hours postadmission; arrangements for postdischarge care; preparing handovers and personalised patient discharge letter; and a discharge conversation 12-24 hours before discharge.

OUTCOME MEASURES

The number of medical and nursing handovers sent within 24 hours. Secondary outcomes were median time between discharge and medical handovers, LOS and unplanned readmissions.

RESULTS

Preintervention 1039 and postintervention 1052 patient records were reviewed. No significant change was observed in the number of medical and nursing handovers sent within 24 hours. The median (IQR) time between discharge and medical handovers decreased from 6.15 (0.96-15.96) to 4.08 (0.33-13.67) days, but no significant difference was found. No intervention effect was observed for LOS and readmission. In subgroup analyses, a reduction of 5.6 days in the median time between discharge and medical handovers was observed in hospitals with high protocol adherence and much attention for implementation.

CONCLUSION

Implementation of a structured discharge bundle did not lead to improved timeliness of patient handovers. However, large interhospital variation was observed and an intervention effect on the median time between discharge and medical handovers was seen in hospitals with high protocol adherence. Future interventions should continue to create awareness of the importance of timely handovers.

TRIAL REGISTRATION NUMBER

NTR5951; Results.

Older persons' experiences of adapting to daily life at home after hospital discharge: a qualitative metasummary

Background

Researchers have shown that hospitalisation can decrease older persons’ ability to manage life at home after hospital discharge. Inadequate practices of discharge can be associated with adverse outcomes and an increased risk of readmission. This review systematically summarises qualitative findings portraying older persons’ experiences adapting to daily life at home after hospital discharge.

Methods

A metasummary of qualitative findings using Sandelowski and Barroso’s method. Data from 13 studies are included, following specific selection criteria, and categorised into four main themes.

Results

Four main themes emerged from the material: (1) Experiencing an insecure and unsafe transition, (2) settling into a new situation at home, (3) what would I do without my informal caregiver? and (4) experience of a paternalistic medical model.

Conclusions

The results emphasise the importance of assessment and planning, information and education, preparation of the home environment, the involvement of the older person and caregivers and supporting self-management in the discharge and follow-up care processes at home. Better communication between older persons, hospital providers and home care providers is needed to improve the coordination of care and facilitate recovery at home. The organisational structure may need to be redefined and reorganised to secure continuity of care and the wellbeing of older persons in transitional care situations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4035-z) contains supplementary material, which is available to authorized users.

Discharge of older patients with chronic diseases: What nurses do and what they record. An observational study

AIMS AND OBJECTIVES

To describe which nursing activities are observed during the discharge of older patients with chronic diseases and to investigate the consistency between the nursing activities actually observed and those documented.

BACKGROUND

The discharge from hospital of older patients with chronic diseases is a critical transition that can lead to dissatisfaction, delays in discharge, re-admission, adverse events and increased mortality. Although nurses' interventions during discharge are important for patient outcomes, little is known about the nursing activities actually performed as compared with those documented.

DESIGN

An observational study of the nursing activities performed during patients' discharge and a retrospective audit of the nursing records of the same patients and nurses.

METHODS

Structured nonparticipant observations were conducted of the activities performed by nurses at discharge. A retrospective audit of the nursing records relating to patient discharge, including the nursing diary and the assessment of critical issues at hospital discharge, was also conducted. The STROBE guidelines were followed (See Supporting Information Appendix S2).

RESULTS

During hospital discharge of 102 patients, 1,224 nursing activities were observed. The number of activities was not related to patients' age, gender and educational level, nor to nurses' postgraduate education. Statistically significant correlations emerged between the number of activities observed and the nurses' work experience.

CONCLUSIONS

A predefined discharge plan guiding nurses' activities during discharge would enable them to respond better to the care needs of elderly patients.

RELEVANCE TO CLINICAL PRACTICE

Results from the study could help clinical nurses to address care priorities of patients at discharge, by using appropriate plans and checklists and improving recording rates. Novice nurses should be supported when caring for elderly patients with chronic disease at discharge.

Ensuring continuity of patient care across the healthcare interface: Telephone follow-up post-hospitalization

AIMS

To implement pharmacist-led, postdischarge telephone follow-up (TFU) intervention and to evaluate its impact on rehospitalization parameters in polypharmacy patients, via comparison with a well-matched control group.

METHOD

Pragmatic, prospective, quasi-experimental study. Intervention patients were matched by propensity score techniques with a control group. Guided by results from a pilot study, clinical pharmacists implemented TFU intervention, added to routine integrated medicines management service.

RESULTS

Using an intention to treat approach, reductions in 30- and 90-day readmission rates for intervention patients compared with controls were 9.9% [odds ratio = 0.57; 95% confidence interval (CI): 0.36-0.90; P < 0.001] and 15.2% (odds ratio = 0.53; 95% CI: 0.36-0.79; P = 0.021) respectively. Marginal mean time to readmission was 70.9 days (95% CI: 66.9-74.9) for intervention group compared with 60.1 days (95% CI: 55.4-64.7) for controls. Mean length of hospital stay compared with control was (8.3 days vs. 6.7 days; P < 0.001). Benefit: cost ratio for 30-day readmissions was 29.62, and 23.58 for 90-day interval. Per protocol analyses gave more marked improvements. In intervention patients, mean concern scale score, using Beliefs about Medicine Questionnaire, was reduced 3.2 (95% CI: -4.22 to -2.27; P < 0.001). Mean difference in Medication Adherence Report Scale was 1.4 (22.7 vs. 24.1; P < 0.001). Most patients (83.8%) reported having better control of their medicines after the intervention.

CONCLUSIONS

Pharmacist-led postdischarge structured TFU intervention can reduce 30- and 90-day readmission rates. Positive impacts were noted on time to readmission, length of hospital stay upon readmission, healthcare costs, patient beliefs about medicines, patient self-reported adherence and satisfaction.

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews

AIM

To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation.

DESIGN

Systematic review of systematic reviews.

DATA SOURCES

We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches.

REVIEW METHODS

Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis.

RESULTS

Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff.

CONCLUSION

Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation.

IMPACT

There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.

Patient readiness for hospital discharge and its relationship to discharge preparation and structural factors: A cross-sectional study

BACKGROUND

Nursing discharge preparation is vital to successful hospital-to-home transitions. However, despite a wealth of evidence on its effectiveness, little is known of the structure- and process-related factors that facilitate or impede its use in clinical practice. Specifically, the associations between unit size and type, leadership support, skill mix, staffing, nurse and patient characteristics, discharge teaching and patient readiness for discharge have rarely been studied.

OBJECTIVES

This study aimed to explore the associations between structure-individual characteristics (i.e., unit, nurse and patient characteristics) and process-related (i.e., teaching of self-care and symptom management) factors and patient readiness for hospital discharge.

DESIGN

A secondary data analysis of the multicentre observational "Matching Registered Nurse services with changing care demands (Match^RN)" study.

SETTING AND PERIOD

Data were collected between September 2015 and January 2016 on 123 surgical, medical and mixed units in 23 Swiss acute care hospitals.

PARTICIPANTS

A total of 1833 registered nurses and 1755 patients were included in the analyses.

METHODS

Structure-, process- and patient readiness-related hospital discharge variables were assessed using validated items either from existing instruments or self-developed. Multilevel mixed-effects logistic regression was used to test associations.

RESULTS

Fewer than half of the patients hospitalized (47.8%) reported readiness for hospital discharge. Fifty-eight percent reported receiving discharge preparation interventions for self-care and 30% for symptom management. Patients' readiness for hospital discharge was significantly lower in larger units (β = -0.001; 95% confidence interval (CI) = -0.002 to -0.001) and on medical units (β = -0.44; 95% CI = -0.70 to -0.19). Higher nurses' experience (β = .004; 95% CI = 0.001 to 0.01), better patient self-reported health (β = -0.11; 95% CI = -0.17 to -0.05), higher patient ratings of self-care teaching (β = 1.33; 95% CI = 1.07-1.59) and symptom management teaching (β = 0.79; 95% CI = 0.52-1.06) were significantly associated with greater patient readiness for hospital discharge.

CONCLUSIONS

Patient readiness for hospital discharge is associated with process- and structure-related factors. Our findings suggest that, for successful uptake in clinical practice, the development and implementation of effective discharge preparation programs should consider the structural context, i.e., patient population, unit size, and experience of nurses within the team. Further research, using a more accurate measure of patient readiness for hospital discharge, is needed to test associations with the nurse work environment and staffing.

Reducing falls in older adults recently discharged from hospital: a systematic review and meta-analysis

Background

older adults are known to have increased falls rates and functional decline following hospital discharge, with substantial economic healthcare costs. This systematic review aimed to synthesise the evidence for effective falls prevention interventions in older adults recently discharged from hospital.

Methods

literature searches of six databases of quantitative studies conducted from 1990 to June 2017, reporting falls outcomes of falls prevention interventions for community-dwelling older adults discharged from hospital were included. Study quality was assessed using a standardised JBI critical appraisal tool (MAStARI) and data pooled using Rev-Man Review Manager®

Results

sixteen studies (total sample size N = 3,290, from eight countries, mean age 77) comprising 12 interventions met inclusion criteria. We found home hazard modification interventions delivered to those with a previous falls history (1 study), was effective in reducing the number of falls (RR 0.63, 95%CI 0.43, 0.93, Low GRADE evidence). Home exercise interventions (3 studies) significantly increased the proportion of fallers (OR 1.74, 95%CI 1.17, 2.60, Moderate GRADE evidence), and did not significantly reduce falls rate (RR 1.27, 95%CI 0.99, 1.62, Very Low GRADE evidence) or falls injury rate (RR 1.16, 95%CI, 0.83,1.63, Low GRADE evidence). Nutritional supplementation for malnourished older adults (1 study) significantly reduced the proportion of fallers (HR 0.41, 95% CI 0.19, 0.86, Low GRADE evidence).

Conclusion

the recommended falls prevention interventions for older adults recently discharged from hospital are to provide home hazard minimisation particularly if they have a recent previous falls history and consider nutritional supplementation if they are malnourished.

Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review

BACKGROUND

Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes.

METHODS

A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively.

RESULTS

Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus.

CONCLUSIONS

This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.

Measurement tools and outcome measures used in transitional patient safety; a systematic review

BACKGROUND

Patients are at risk for harm when treated simultaneously by healthcare providers from different healthcare organisations. To assess current practice and improvements of transitional patient safety, valid measurement tools are needed.

AIM AND METHODS

To identify and appraise all measurement tools and outcomes that measure aspects of transitional patient safety, PubMed, Cinahl, Embase and Psychinfo were systematically searched. Two researchers performed the title and abstract and full-text selection. First, publications about validation of measurement tools were appraised for quality following COSMIN criteria. Second, we inventoried all measurement tools and outcome measures found in our search that assessed current transitional patient safety or the effect of interventions targeting transitional patient safety.

RESULTS

The initial search yielded 8288 studies, of which 18 assessed validity of measurement tools of different aspects of transitional safety, and 191 assessed current transitional patient safety or effect of interventions. In the validated measurement tools, the overall quality of content and structural validity was acceptable; other COSMIN criteria, such as reliability, measurement error and responsiveness, were mostly poor or not reported. In our outcome inventory, the most frequently used validated outcome measure was the Care Transition Measure (n = 9). The most frequently used non-validated outcome measures were: medication discrepancies (n = 98), hospital readmissions (n = 55), adverse events (n = 34), emergency department visits (n = 33), (mental or physical) health status (n = 28), quality and timeliness of discharge summary, and patient satisfaction (n = 23).

CONCLUSIONS

Although no validated measures exist that assess all aspects of transitional patient safety, we found validated measurement tools on specific aspects. Reporting of validity of transitional measurement tools was incomplete. Numerous outcome measures with unknown measurement properties are used in current studies on safety of care transitions, which makes interpretation or comparison of their results uncertain.

Impact of emergency physician-provided patient education about alternative care venues

OBJECTIVES

Interventions that focus on educating patients appear to be the most effective in directing healthcare utilization to more appropriate venues. We sought to evaluate the effects of mailed information and a brief scripted educational phone call from an emergency physician (EP) on subsequent emergency department (ED) utilization by low-risk adults with a recent treat-and-release ED visit.

STUDY DESIGN

Patients were randomized into 3 groups for post-ED follow-up: EP phone call with mailed information, mailed information only, and no educational intervention. Each intervention group was compared with a set of matched controls.

METHODS

We undertook this study in 6 EDs within an integrated healthcare delivery system. Overall, 9093 patients were identified; the final groups were the phone group (n = 609), mail group (n = 771), and matched control groups for each (n = 1827 and n = 1542, respectively). Analysis was stratified by age (<65 and ≥65 years). Patients were educated about available venues of care delivery for their future medical needs. The primary outcome was the rate of 6-month ED utilization after the intervention compared with the 6-month utilization rate preceding the intervention.

RESULTS

Compared with matched controls, subsequent ED utilization decreased by 22% for patients 65 years or older in the phone group (P = .04) and by 27% for patients younger than 65 years in the mail group (P = .03).

CONCLUSIONS

ED utilization subsequent to a low-acuity ED visit decreased after a brief post-ED education intervention by an EP explaining alternative venues of care for future medical needs. Response to the method of communication (phone vs mail) varied significantly by patient age.

[Perception of Primary Care physicians on the integration with cardiology through continuity of healthcare programs in secondary prevention]

OBJECTIVE

To determine the perception of Primary Care (PC) physicians on the integration with cardiology (CA) through continuity of healthcare programs.

MATERIAL AND METHODS

A cross-sectional and multicentre study was conducted, in which a total of 200 PC physicians from all over Spain completed a qualitative survey that evaluated the level of integration with CA in secondary prevention. Physicians were grouped according to the level of PC-CA integration.

RESULTS

The integration between CA and PC was good, but it was better in those centres with a higher integration (74.0% vs. 60.0%; p=.02) and in general, physicians considered that integration had improved (92.0% vs. 73.0%; p<.001). Almost all PC physicians received the hospital discharge report. The majority of the hospital discharge reports included recommendations about the CA and PC follow-up, control of risk factors, as well as the duration of secondary prevention treatment, with not significant differences according to the level of integration. In 55.8%, 63.6%, and 51.3% of hospital discharge reports, indications were given on when to perform the follow-up blood analysis, as well as information about returning to working life and sexual activity, respectively. The most common communication method was the paper-based report (75 vs. 84%; p=NS). The communication between healthcare levels was greater in those Primary Care centres with a higher level of integration, as well as periodicity of the communication and the satisfaction of physicians (80.0% vs. 63.0%; p=.005).

CONCLUSIONS

The level of integration between PC and CA is, in general, satisfactory, but those centres with a higher level of integration benefit more from a greater communication and satisfaction.

Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review

BACKGROUND

Many discharge interventions are developed to reduce unplanned hospital readmissions, but it is unclear which interventions are more effective.

OBJECTIVES

The objective of this review was to identify discharge interventions from hospital to home that reduce hospital readmissions within three months and to understand their effect on secondary outcome measures.

INCLUSION CRITERIA

Participants were adults (18 years or older) discharged from a medical or surgical ward.The included interventions had to be designed to ease the care transition from hospital to home or to prevent problems after hospital discharge.This review considered only randomized controlled trials.The primary outcome measure was hospital readmission within three months after discharge. Secondary outcomes included patient satisfaction, return to emergency departments and mortality.

SEARCH STRATEGY

Studies in English between January 1990 and July 2014 were considered for inclusion. The databases searched were PubMed, Web of Science, Embase and CINAHL.

METHODOLOGICAL QUALITY

Methodological validity was assessed by two reviewers prior to inclusion using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Quantitative data were independently extracted by the two reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

Meta-analysis was performed by using a random effect model; data were pooled using Mantel-Haenszel methods. For subgroups analysis only papers with critical appraisal score of seven or more were selected.

RESULTS

Meta-analysis was performed on 47 studies. The overall relative risk for hospital readmission was 0.77 [95% CI, 0.70-0.84] (p<0.00001). The relative risk for return to the emergency department was 0.75 [95% CI, 0.55-1.01] (p=0.06) and for mortality 0.70 [95% CI, 0.48-1.01] (p=0.06). Patient satisfaction improved in favor of the intervention group in five out of the six studies evaluating patient satisfaction.Exploratory subgroup analysis found that interventions starting during hospital stay and continuing after discharge were more effective in reducing readmissions compared to interventions starting after discharge (between subgroup difference p=0.01). Multicomponent interventions were not more effective compared to single component interventions (between subgroup difference p=0.54). Interventions oriented towards patient empowerment were more effective compared to all other interventions (between subgroup difference p=0.02).

CONCLUSIONS

Interventions designed to improve the care transition from hospital to home are effective in reducing hospital readmission. These interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Enhancing patient empowerment is a key factor in reducing hospital readmissions.Interventions to reduce hospital readmissions should start during hospital stay and continue in the community (grade A recommendation). This requires financial systems to support and facilitate collaboration between hospitals and home care.Interventions that support patient empowerment are more effective in reducing hospital readmissions (grade B recommendation). To promote patient empowerment caregivers must be trained to increase patients' capacity to self-care.Future research should focus on interventions that improve patient empowerment and the effects of discharge interventions after more than three months.

BRASS score and complex discharge: a pilot study

Aims:

A highly functional continuity of patient care, which is linked to the reduction of the risk of long-term hospitalization, above all for ‘at-risk’ patients. Research into an objective, reliable instrument for redirecting individual results to organizational aims to extend the entire country, is a fundamental step to move from a reactive assistance approach to a pro-active one.

Methods:

An observational and descriptive retrospective study was carried out July - November 2014 in two Italian state hospitals, completing the BRASS Index within 48/72 hours of admission.

Results:

The study group consisted of 122 inpatients. A correlation presented itself, albeit low (ρ=0.05191), between age and the number of ‘revolving door’ admissions; a medium correlation (ρ=0.485131) between age and risk band (according to BRASS).

Conclusions:

The BRASS Index is straightforward and swift, and can prove a valuable tool in directing nurses’ attention to those patients most at risk of prolonged hospitalization. (www.actabiomedica.it)

Using patient data to optimize an expert-based guideline on convalescence recommendations after gynecological surgery: a prospective cohort study

BACKGROUND

Convalescence advice is often based on tradition and anecdote from health care providers, rather than being based on experiences from patients themselves. The aim of this study was to analyse recovery in terms of resumption of various daily activities including work, following different laparoscopic and abdominal surgery in order to optimize an expert-based guideline on convalescence recommendations.

METHODS

This is a prospective cohort study conducted in nine general and one university hospital in the Netherlands. Women aged 18-65 years and scheduled for a hysterectomy (laparoscopic, vaginal, abdominal) and/or laparoscopic adnexal surgery (n = 304) were eligible to participate. Preoperatively, participants were provided with tailored expert-based convalescence recommendations on the graded resumption of several daily activities including sitting, standing, walking, climbing stairs, bending, lifting, driving, cycling, household chores, sport activities and return to work (RTW). Postoperatively, time until the resumption of these activities was tracked. Convalescence recommendations were considered correct when at least 25% and less than 50% of the women were able to resume an activity before or at the recommended recovery time.

RESULTS

There was a wide variation in the duration until the resumption of daily activities within and between groups of patients undergoing different types of surgery. Recovery times lengthened with increasing levels of physical burden as well as with increasing levels of invasiveness of the surgery. For the majority of activities actual recovery times exceeded the recovery time recommended by the expert panel.

CONCLUSIONS

This study provided insight in the resumption of daily activities after gynecological surgery and the adequacy of an expert-based convalescence guideline in clinical practice. Patient data was used to optimize the convalescence recommendations.

TRIAL REGISTRATION

Dutch trial registry, NTR2087 (August 2009) and NTR2933 (June 2011).

Managing febrile neutropenia in adult cancer patients: an integrative review of the literature

ABSTRACT Objective: To analyze the interventions performed by health professionals with a view to managing chemotherapy-induced febrile neutropenia. Method: Integrative literature review, the sample of 12 primary articles was selected from the following databases: LILACS, SciELO, BVS, PubMed, CINAHL and Web of Science. Results: There was a prevalence of studies, realized by doctors, focused on pharmacological treatment and on the association of methods for greater diagnostic accuracy of febrile neutropenia. A study was found on pharmaceutical management regarding antibiotic dosing efficacy and a study indicating that nurses could contribute to the identification of elderly patients who would benefit from prophylactic use of growth factor. Conclusion: There was a shortage of studies involving the participation of other health professionals, besides the doctors, and a knowledge gap regarding interprofessional practice in the management of interventions specific to their area of specialism, joint interventions and non-pharmacological interventions.

Effectiveness of structured planned post discharge support to patients with chronic obstructive pulmonary disease for reducing readmission rates: a systematic review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, characterized by airflow limitation. The disease has a significant impact on the lives of patients and is a challenge for the health care due to readmissions to hospitals.

OBJECTIVES

This review aimed to identify, appraise and synthesize the best available evidence on the effectiveness of discharge interventions that can reduce readmission of patients with COPD.

TYPES OF PARTICIPANTS

Hospitalized patients, aged 18 years or over, who had been diagnosed with COPD and were admitted to hospital due to acute exacerbation.

TYPES OF INTERVENTIONS

Studies that evaluated discharge interventions that supported patients managing symptoms of COPD.

TYPES OF STUDIES

Randomized controlled trials, non-randomized controlled trials, quasi-experimental or cohort studies.

OUTCOMES

Readmission, defined as hospitalization to the same or different hospital for any reason within the following year after discharge.

SEARCH STRATEGY

Multiple databases (PubMed, Embase, CINAHL, the Cochrane Library, Pedro, Web of Science, Turning Research Into Practice [Trip] and Scopus) were searched from 1990 to June 2015. Studies published in English or Scandinavian.

METHODOLOGICAL QUALITY

Two independent reviewers used the standard critical appraisal tool from the Joanna Briggs Institute to assess the methodological quality of studies. All studies were of good methodological quality.

DATA EXTRACTION

The process of data extraction was undertaken independently by two reviewers using tools from the Joanna Briggs Institute.

DATA SYNTHESIS

A narrative description of each study was performed. Outcomes were reported as the event rate (ER) in the intervention and control groups. Based on the ER relative risk reduction (RRR), absolute risk reduction (ARR), the number needed to treat (NNT), and relative risk (RR) with 95% confidence intervals were calculated. Continuous data were reported in natural units.

RESULTS

This review includes ten studies all testing a mix of interventions. A meta-analysis included six studies, four at 30 days follow-up with RR 0.67 (0.45 to 0.98) and 180 days follow-up with RR 0.74 (0.51 to 1.08). The analysis could not identify a single set of interventions that could be recommended.

CONCLUSIONS

Post discharge support and interventions in patients with COPD significantly reduce the readmission rate within 30 days after discharge from hospital and the interventions may significantly reduce readmission up to 180 days after initial discharge. This is a significant finding from the clinical and practical perspective.

A retrospective cohort study of high-impact users among patients with cerebrovascular conditions

OBJECTIVE

To apply group-based trajectory modelling (GBTM) to the hospital administrative data to evaluate, model and visualise trends and changes in the frequency of long-term hospital care use of the subgroups of patients with cerebrovascular conditions.

DESIGN

A retrospective cohort study of patients with cerebrovascular conditions.

SETTINGS

Secondary care of all patients with cerebrovascular conditions admitted to English National Hospital Service hospitals.

PARTICIPANTS

All patients with cerebrovascular conditions identified through national administrative data (Hospital Episode Statistics) and subsequent emergency hospital admissions followed up for 4 years.

MAIN OUTCOME MEASURE

Annual number of emergency hospital readmissions.

RESULTS

GBTM model classified patients with intracranial haemorrhage (n=2605) into five subgroups, whereas ischaemic stroke (n=34 208) and transient ischaemic attack (TIA) (n=20 549) patients were shown to have two conventional groups, low and high impact. The covariates with significant association with high-impact users (17.1%) among ischaemic stroke were epilepsy (OR 2.29), previous stroke (OR 2.18), anxiety/depression (OR 1.63), procedural complication (OR 1.43), admission to intensive therapy unit (ITU) or high dependency unit (HDU) (OR 1.42), comorbidity score (OR 1.36), urinary tract infections (OR 1.32), vision loss (OR 1.32), chest infections (OR 1.25), living alone (OR 1.25), diabetes (OR 1.23), socioeconomic index (OR 1.20), older age (OR 1.03) and prolonged length of stay (OR 1.00). The covariates associated with high-impact users among TIA (20.0%) were thromboembolic event (OR 3.67), previous stroke (OR 2.51), epilepsy (OR 2.25), hypotension (OR 1.86), anxiety/depression (OR 1.63), amnesia (OR 1.62), diabetes (OR 1.58), anaemia (OR 1.55), comorbidity score (OR 1.39), atrial fibrillation (OR 1.27), living alone (OR 1.25), socioeconomic index (OR 1.13), older age (OR 1.04) and prolonged length of stay (OR 1.02). The high-impact users (0.5%) among intracranial haemorrhage were strongly associated with thromboembolic event (OR 20.3) and inversely related to older age (OR 0.58).

CONCLUSION

GBTM effectively assessed trends in the use of hospital care by the subgroups of patients with cerebrovascular conditions. High-impact users persistently had higher annual readmission during the follow-up period.

Sequence Analysis of Long-Term Readmissions among High-Impact Users of Cerebrovascular Patients

Objective

Understanding the chronological order of the causes of readmissions may help us assess any repeated chain of events among high-impact users, those with high readmission rate. We aim to perform sequence analysis of administrative data to identify distinct sequences of emergency readmissions among the high-impact users.

Methods

A retrospective cohort of all cerebrovascular patients identified through national administrative data and followed for 4 years.

Results

Common discriminating subsequences in chronic high-impact users (n = 2863) of ischaemic stroke (n = 34208) were “urological conditions-chest infection,” “chest infection-urological conditions,” “injury-urological conditions,” “chest infection-ambulatory condition,” and “ambulatory condition-chest infection” (p < 0.01). Among TIA patients (n = 20549), common discriminating (p < 0.01) subsequences among chronic high-impact users were “injury-urological conditions,” “urological conditions-chest infection,” “urological conditions-injury,” “ambulatory condition-urological conditions,” and “ambulatory condition-chest infection.” Among the chronic high-impact group of intracranial haemorrhage (n = 2605) common discriminating subsequences (p < 0.01) were “dementia-injury,” “chest infection-dementia,” “dementia-dementia-injury,” “dementia-urine infection,” and “injury-urine infection.” Conclusion. Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

Conclusion

Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

Reducing Pediatric Readmissions: Using a Discharge Bundle Combined With Teach-back Methodology

The authors describe a quality improvement initiative aimed at decreasing unplanned 7- and 30-day readmission rates in an urban, pediatric, tertiary care hospital. A stepwise approach was used to disseminate the pilot initiative across 16 inpatient units. Use of a teach-back methodology combined with a discharge bundle resulted in an 8% reduction in 7-day readmission and 10% reduction in 30-day readmission over 16 months.

Adherence to oral cancer therapy in older adults: The International Society of Geriatric Oncology (SIOG) taskforce recommendations

There is an increasing trend towards using oral systemic therapy in patients with cancer. Compared to parenteral therapy, oral cancer agents offer convenience, have similar efficacy, and are preferred by patients, consequently making its use appealing in older adults. However, adherence is required to ensure its efficacy and to avoid compromising treatment outcomes, especially when the treatment goal is curative, or in case of symptomatic/rapidly progressing disease, where dose-intensity is important. This opens a new challenge for clinicians, as optimizing patient adherence is challenging, particularly due to lack of consensus and scarcity of available clinical evidence. This manuscript aims to review the impact of age-related factors on adherence, summarize the evidence on adherence, recommend methods for selecting patients suitable for oral cancer agents, and advise monitoring interventions to promote adherence to treatment.