Impacts of an Acute Care Telenursing Program on Discharge, Patient Experience, and Nursing Experience: Retrospective Cohort Comparison Study

BACKGROUND

Despite widespread growth of televisits and telemedicine, it is unclear how telenursing could be applied to augment nurse labor and support nursing.

OBJECTIVE

This study evaluated a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients.

METHODS

A retrospective, observational cohort comparison was performed in a large academic hospital system (approximately 2100 beds) in Houston, Texas, comparing patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, with patients who did not participate (nontelenursing cohort) in the same units and timeframe. We used a case mix index analysis to confirm comparable patient cases between groups. The outcomes investigated were patient experience, measured using the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHCPS) survey; nursing experience, measured by a web-based questionnaire with quantitative multiple-choice and qualitative open-ended questions; time of discharge during the day (from electronic health record data); and duration of discharge education processes.

RESULTS

Case mix index analysis found no significant case differences between cohorts (P=.75). For the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHCPS domains. Scores for "communication with doctors" and "would recommend hospital" were improved significantly (P=.03 and P=.04, respectively) in 1 unit in phase 1. The impact of telenursing in phases 2 and 3 was mixed. However, "communication with doctors" was significantly improved in 2 units (P=.049 and P=.002), and the overall rating of the hospital and the "would recommend hospital" scores were significantly improved in 1 unit (P=.02 and P=04, respectively). Of 289 nurses who were invited to participate in the survey, 106 completed the nursing experience survey (response rate 106/289, 36.7%). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was very helpful or somewhat helpful to them as bedside nurses. The only noticeable difference between the telenursing and nontelenursing cohorts for the time of day discharge was a shift in the volume of patients discharged before 2 PM compared to those discharged after 2 PM at a hospital-wide level. The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice (nontelenursing cohort) of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation time study.

CONCLUSIONS

This study shows that ACTN programs are feasible and associated with improved outcomes for patient and nursing experience and reducing time allocated to admission and discharge education.

Barriers and facilitators of readiness for hospital discharge in patients with myocardial infarction: a qualitative study: quality improvement study

Background

Readiness for hospital discharge (RHD) in patients with myocardial infarction (MI) is a key concept in the discharge process. This study was conducted to explain the barriers and facilitators of preparation for discharge in patients with MI.

Materials and methods

A qualitative study was conducted using conventional content analysis from April 2021 to 2022. Data collection was done in a targeted manner through semi-structured interviews until the data saturation stage. Nineteen participants (11 patients, 3 family members, and 5 healthcare team) were interviewed. Data analysis was done in eight steps according to the suggested steps of Graneheim and Lundman. MAXQDA18 software was used for coding.

Results

From the interviews, 348 primary codes, 11 sub-categories, and 5 categories were extracted. Finally, after continuous analysis and comparison of interviews, codes, and categories, two themes including "supporting platform" and "caring atmosphere" were extracted, which were the result of the participants' experience and understanding of the barriers and facilitators of RHD. The supporting platform included "family support" and "social support" and the caring atmosphere included "care gaps" and "professional healthcare team performance".

Conclusion

The results of this study indicate several factors affecting RHD in heart attack patients. According to the results of the study, the participation of the patient, family, healthcare team, and community in creating RHD is recommended. It is also suggested to pay attention to these factors in care and treatment planning to help improve health and control complications and prevent re-hospitalization in these patients.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19

BACKGROUND

Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge.

METHODS

Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization.

RESULTS

Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization.

CONCLUSIONS

HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Engaging patients in designing a transmural allied health pathway: A qualitative exploration of hospital-to-home transitions

INTRODUCTION

The transition from hospital to home is often suboptimal, resulting in patients not receiving the necessary allied healthcare after discharge. This may, in turn, lead to delayed recovery, a higher number of readmissions, more emergency department visits and an increase in mortality and healthcare costs. This study aimed to gain insight into patients' experiences, perceptions, and needs regarding hospital-to-home transition, focusing on allied healthcare as a first step towards the development of a transitional integrated allied healthcare pathway for patients with complex care needs after hospital discharge.

METHODS

We conducted semistructured interviews with patients. Participants were recruited from universities and general hospitals in the Amsterdam region between May and July 2023. They were eligible if they (1) were discharged from the hospital minimally 3 and maximally 12 months after admission to an oncologic surgery department, internal medicine department, intensive care unit, or trauma centre, (2) received hospital-based care from at least one allied healthcare provider, who visited the patient at least twice during hospital admission, (3) spoke Dutch or English and (4) were 18 years or older. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis of the interview data.

RESULTS

Nineteen patients were interviewed. Three themes emerged from the analysis. 'Allied healthcare support during transition' depicts patients' positive experiences when they felt supported by allied health professionals during the hospital-to-home transition. 'Patient and family involvement' illustrates how much patients value the involvement of their family members during discharge planning. 'Information recall and processing' portrays the challenges of understanding and remembering overwhelming amounts of information, sometimes unclear and provided at the wrong moment. Overall, patients' experiences of transitional care were positive when they were involved in the discharge process. Negative experiences occurred when their preferences for postdischarge communication were ignored.

CONCLUSIONS

This study suggests that allied health professionals need to continuously collaborate and communicate with each other to provide patients and their families with the personalized support they need. To provide high-quality and person-centred care, it is essential to consider how, when, and what information to provide to patients and their families to allow them to contribute to their recovery actively.

PATIENT OR PUBLIC CONTRIBUTION

The interview guide for this manuscript was developed with the assistance of patients, who reviewed it and provided us with feedback. Furthermore, patients provided us with their valuable lived experiences by participating in the interviews conducted for this study.

Nine recommendations for the emergency department for patients presenting with low back pain based on management and post-discharge outcomes in an Australian, tertiary emergency department

OBJECTIVE

To ascertain and develop recommendations for analgesic management, discharge planning and further healthcare utilisation of adults presenting to an Australian tertiary ED with radicular or low back pain (LBP).

METHODS

This prospective cohort study included adults presenting with non-specific LBP or radicular pain to an Australian tertiary ED. Participants with trauma/cancer-related pain, and those requiring hospital admission or surgical interventions were excluded. The primary outcome was pharmacological and non-pharmacological management delivered in ED, retrospectively collected via electronic medical records. The secondary outcomes include discharge management use, and changes made due to post-discharge healthcare utilisation, as observed by weekly telephone questionnaires over 4-weeks follow-up.

RESULTS

Of the 100 participants recruited, 94 completed follow-up. In ED, pharmacological management was received by 85%, including opioids (62%) and non-steroidal anti-inflammatory drugs (NSAIDS, 63%). Non-pharmacological management was received by 73%, including patient education (71%) and exercise prescription (37%). In the first-week post-discharge, changes to initial discharge plan occurred in 50%, mostly carried out by GPs (76%). Over the follow-up period, 51% received additional investigations/referrals. Pharmacological use decreased by 38% and non-pharmacological use decreased by 10%. 16% of opioid-naïve patients continued using opioids 4-weeks post-discharge.

CONCLUSION

ED presentations for LBP were more often treated pharmacologically than non-pharmacologically, with opioids commonly prescribed and NSAIDs potentially under-utilised. Post-discharge, additional investigations/referrals, discharge analgesia reductions and maintenance of non-pharmacological management were common. Opioid initiation as a result of LBP presentations, signifies a potential 'gateway' towards unintentional long-term use. Key study findings form our nine recommendations to inform ED LBP pain management.

Characteristics and Hospital Outcomes of 1403 Patients Hospitalized at Community Hospitals With Ankylosing Spondylitis

Background

In this study, we aimed to assess the hospital course, outcomes after hospitalization, and predictors of outcomes in patients with ankylosing spondylitis (AS).

Methods

We included 1403 patients with AS between 2016 and 2021 who were identified using International Classification of Disease (ICD) codes from a large for-profit healthcare system database. Demographics and clinical characteristics were compared between those who had a favorable outcome, defined as being discharged to home without readmission within 3 months of discharge, versus those who had an unfavorable outcome. A stepwise logistic regression was used to identify demographic and clinical characteristics associated with home discharge and readmission.

Results

The mean age for all AS patients was 56.06 ± 17.01 years, which was younger in the favorable outcome group, and 82.47% of patients were discharged to home after the average length of stay of 3.72 ± 4.09 days, also shorter in the favorable outcome group. Of 1403 patients, 37.56% were readmitted within 3 months of discharge, at a lower rate in the group with home discharge. Opioids were the most commonly used medication during hospitalization (67.07%), prescribed at a lower rate in the favorable outcome group. Medical coverage by Medicare and Medicaid, fall at admission, hospital-acquired anemia, steroid, acetaminophen, muscle relaxant use, and an increased dose of morphine milligram equivalent at discharge were significantly associated with decreased odds of home discharge. Surgical procedures during admission, gastrointestinal complications, discharge to inpatient rehabilitation units, and use of benzodiazepine were associated with an increased risk of readmission within 3 months.

Conclusion

Recognizing factors that put patients with AS at risk of unfavorable outcomes is useful information to improve patient care during hospitalization.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

Alternative Payment Models and Patient-Reported Quality of Preparation for Discharge: A Retrospective Longitudinal Study

Preparing patients for posthospital care may improve readmission risk. Alternative payment models (APMs) incent hospitals to reduce readmissions by tying payment to outcomes. The impact of APMs on preparation for discharge is not well understood. We assessed whether patient-reported preparation for posthospital care was associated with reduced readmissions, and whether APM participation was associated with improved preparation for posthospital care. We used mixed-effects regression on retrospective (2013-2017) observational data for 2685 U.S. hospitals. We measured patient-reported preparation for posthospital care using the 3-Item Care Transition Measure and readmission using 30-day all-cause risk-adjusted readmissions from Hospital Compare. Participation in accountable care organizations (ACOs), Medical Homes, and Medicare's Bundled Payments for Care Improvement program was obtained from Medicare, the American Hospital Association's Annual Survey, and Leavitt Partner's ACO database. We found that APMs are not associated with improved preparation for posthospital care, even though it was associated with reduced readmissions (Marginal Effect: -0.012 percentage points). This may be because hospitals are not investing in patient engagement. This study has limited insight into causality and reduced generalizability among smaller, rural, and non-teaching hospitals.

Racial disparities among mild stroke survivors: predictors of home discharge from a retrospective analysis

BACKGROUND

Half of all strokes are classified as mild, and most mild stroke survivors are discharged home after their initial hospitalization without any post-acute rehabilitation despite experiencing cognitive, psychosocial, motor, and mobility impairments.

OBJECTIVES

To investigate the demographic and clinical characteristics of mild stroke survivors and their association with discharge location.

METHODS

This is a retrospective analysis of mild stroke survivors from 2015-2023 in an academic medical center. Demographic characteristics, clinical measures, and discharge locations were obtained from the electronic health record. The Social Vulnerability Index was used to measure the community vulnerability. Associations between variables and discharge location were examined using bivariate logistic regression analysis.

RESULTS

There were 2,953 mild stroke survivors included in this study. The majority of participants were White (65.46%), followed by Black (19.40%). Black stroke survivors and individuals with higher social vulnerability had a higher proportion of discharges to skilled nursing facilities (p = 0.001). Black patients and patients with high vulnerability in housing type and transportation were less likely to be discharged home.

CONCLUSIONS

Mild stroke survivors have a high rate of home discharge, potentially because less severe stroke symptoms have a reduced need for intensive care. Racial disparities in discharge location were evident, with Black stroke survivors experiencing higher rates of institutionalized care and lower likelihood of being discharged home compared to White counterparts, emphasizing the importance of addressing these disparities for equitable healthcare delivery and optimal outcomes.

Weaknesses in the continuity of care for preterm infants discharged from the neonatal unit

OBJECTIVE

To identify weaknesses in the continuity of care for preterm infants discharged from a neonatal unit, based on the perspective of professionals in the family health strategy.

METHOD

Qualitative research, carried out with 16 professionals from four health regions in a capital city in the center-west of Brazil. Data collection took place from October to December 2020, through semi-structured, individual, and in-person interviews. Data underwent content analysis, supported by the concept of continuity of care.

RESULTS

The analysis consisted of three categories: Challenges for care in the unit and referral to specialized services; weak interactions between the preterm baby's family and health professionals; Information: essential aspect for the connection between health professionals and the family of the preterm newborn.

CONCLUSION

Health services are shown to be fragile in terms of the dimensions of continuity of care, contributing to the discontinuity of care for preterm children.

Co-design of an intervention to improve patient participation in discharge medication communication

Patients can experience medication-related harm and hospital readmission because they do not understand or adhere to post-hospital medication instructions. Increasing patient medication literacy and, in turn, participation in medication conversations could be a solution. The purposes of this study were to co-design and test an intervention to enhance patient participation in hospital discharge medication communication. In terms of methods, co-design, a collaborative approach where stakeholders design solutions to problems, was used to develop a prototype medication communication intervention. First, our consumer and healthcare professional stakeholders generated intervention ideas. Next, inpatients, opinion leaders, and academic researchers collaborated to determine the most pertinent and feasible intervention ideas. Finally, the prototype intervention was shown to six intended end-users (i.e. hospital patients) who underwent usability interviews and completed the Theoretical Framework of Acceptability questionnaire. The final intervention comprised of a suite of three websites: (i) a medication search engine; (ii) resources to help patients manage their medications once home; and (iii) a question builder tool. The intervention has been tested with intended end-users and results of the Theoretical Framework of Acceptability questionnaire have shown that the intervention is acceptable. Identified usability issues have been addressed. In conclusion, this co-designed intervention provides patients with trustworthy resources that can help them to understand medication information and ask medication-related questions, thus promoting medication literacy and patient participation. In turn, this intervention could enhance patients' medication self-efficacy and healthcare utilization. Using a co-design approach ensured authentic consumer and other stakeholder engagement, while allowing opinion leaders and researchers to ensure that a feasible intervention was developed.

Admission avoidance hospital at home

BACKGROUND

Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review.

OBJECTIVES

To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field.

SELECTION CRITERIA

Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

MAIN RESULTS

We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up.

AUTHORS' CONCLUSIONS

Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

The use of interpreter services and its barriers faced by hospital staff when accessing interpreters for patients with low English proficiency during the COVID-19 pandemic

ISSUE ADDRESSED

Patients with low English proficiency (LEP) often require interpreter services in health care, however, their usage remains low. This study aimed to explore the barriers to accessing interpreter services and suggests ways services can be improved in hospitals.

METHODS

We conducted focus groups with clinicians and a retrospective audit of patient records. The clinicians were recruited from the inpatient wards and Emergency Department in a Sydney hospital, August 2022. The focus group discussion explored clinicians' experiences using an interpreter, and ways to improve access to the service. It was recorded, transcribed and coded thematically using Braun and Clarke's (2006) 6-step framework. The patient record data were linked with the interpreter service booking data to determine whether patients flagged as requiring an interpreter on admission were provided with the service.

RESULTS

Two focus groups were conducted with clinicians (N = 9 in total). Long wait times for telephone interpreters, an inflexible booking system, and low availability of in-person interpreters were identified as the barriers. The COVID-19 pandemic also impacted in-person service provision.

CONCLUSION

Some systemic barriers including an inflexible booking process and long wait times for immediate interpreter services were identified. The low use of interpreter services is attributed to the difficulties accessing the service and poor documentation in patient records. SO WHAT?: Greater availability of in-person interpreter services, an upgraded booking system, and effective implementation the NSW Health Standard Procedures for Working with Health Care Interpreters will address some of these barriers.

Dynamic Prediction of Post-Acute Care Needs for Hospitalized Medicine Patients

OBJECTIVES

Use patient demographic and clinical characteristics at admission and time-varying in-hospital measures of patient mobility to predict patient post-acute care (PAC) discharge.

DESIGN

Retrospective cohort analysis of electronic medical records.

SETTING AND PARTICIPANTS

Patients admitted to the two participating Hospitals from November 2016 through December 2019 with ≥72 hours in a general medicine service.

METHODS

Discharge location (PAC vs home) was the primary outcome, and 2 time-varying measures of patient mobility, Activity Measure for Post-Acute Care (AM-PAC) Mobility "6-clicks" and Johns Hopkins Highest Level of Mobility, were the primary predictors. Other predictors included demographic and clinical characteristics. For each day of hospitalization, we predicted discharge to PAC using the demographic and clinical characteristics and most recent mobility data within a random forest (RF) for survival, longitudinal, and multivariate (RF-SLAM) data. A regression tree for the daily predicted probabilities of discharge to PAC was constructed to represent a global summary of the RF.

RESULTS

There were 23,090 total patients and compared to PAC, those discharged home were younger (64 vs 71), had shorter length of stay (5 vs 8 days), higher AM-PAC at admission (43 vs 32), and average AM-PAC throughout hospitalization (45 vs 35). AM-PAC was the most important predictor, followed by age, and whether the patient lives alone. The area under the hospital day-specific receiver operating characteristic curve ranged from 0.76 to 0.79 during the first 5 days. The global summary tree explained 75% of the variation in predicted probabilities for PAC from the RF. Sensitivity (75%), specificity (70%), and accuracy (72%) were maximized at a PAC probability threshold of 40%.

CONCLUSIONS AND IMPLICATIONS

Daily assessment of patient mobility should be part of routine practice to help inform care planning by hospital teams. Our prediction model could be used as a valuable tool by multidisciplinary teams in the discharge planning process.

Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study

Purpose

The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy.

Patients and Methods

The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert.

Results

332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives.

Conclusion

Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.

Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants

BACKGROUND

Infants born preterm are at increased risk of cognitive and motor impairments compared with infants born at term. Early developmental interventions for preterm infants are targeted at the infant or the parent-infant relationship, or both, and may focus on different aspects of early development. They aim to improve developmental outcomes for these infants, but the long-term benefits remain unclear. This is an update of a Cochrane review first published in 2007 and updated in 2012 and 2015.

OBJECTIVES

Primary objective To assess the effect of early developmental interventions compared with standard care in prevention of motor or cognitive impairment for preterm infants in infancy (zero to < three years), preschool age (three to < five years), and school age (five to < 18 years). Secondary objective To assess the effect of early developmental interventions compared with standard care on motor or cognitive impairment for subgroups of preterm infants, including groups based on gestational age, birthweight, brain injury, timing or focus of intervention and study quality.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and trial registries in July 2023. We cross-referenced relevant literature, including identified trials and existing review articles.

SELECTION CRITERIA

Studies included randomised, quasi-randomised controlled trials (RCTs) or cluster-randomised trials of early developmental intervention programmes that began within the first 12 months of life for infants born before 37 weeks' gestational age (GA). Interventions could commence as an inpatient but had to include a post discharge component for inclusion in this review. Outcome measures were not prespecified, other than that they had to assess cognitive outcomes, motor outcomes or both. The control groups in the studies could receive standard care that would normally be provided.

DATA COLLECTION AND ANALYSIS

Data were extracted from the included studies regarding study and participant characteristics, timing and focus of interventions and cognitive and motor outcomes. Meta-analysis using RevMan was carried out to determine the effects of early developmental interventions at each age range: infancy (zero to < three years), preschool age (three to < five years) and school age (five to < 18 years) on cognitive and motor outcomes. Subgroup analyses focused on GA, birthweight, brain injury, time of commencement of the intervention, focus of the intervention and study quality. We used standard methodological procedures expected by Cochrane to collect data and evaluate bias. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Forty-four studies met the inclusion criteria (5051 randomly assigned participants). There were 19 new studies identified in this update (600 participants) and a further 17 studies awaiting outcomes. Three previously included studies had new data. There was variability in the focus and intensity of the interventions, participant characteristics, and length of follow-up. All included studies were either single or multicentre trials and the number of participants varied from fewer than 20 to up to 915 in one study. The trials included in this review were mainly undertaken in middle- or high-income countries. The majority of studies commenced in the hospital, with fewer commencing once the infant was home. The focus of the intervention programmes for new included studies was increasingly targeted at both the infant and the parent-infant relationship. The intensity and dosages of interventions varied between studies, which is important when considering the applicability of any programme in a clinical setting. Meta-analysis demonstrated that early developmental intervention may improve cognitive outcomes in infancy (developmental quotient (DQ): standardised mean difference (SMD) 0.27 standard deviations (SDs), 95% confidence interval (CI) 0.15 to 0.40; P < 0.001; 25 studies; 3132 participants, low-certainty evidence), and improves cognitive outcomes at preschool age (intelligence quotient (IQ); SMD 0.39 SD, 95% CI 0.29 to 0.50; P < 0.001; 9 studies; 1524 participants, high-certainty evidence). However, early developmental intervention may not improve cognitive outcomes at school age (IQ: SMD 0.16 SD, 95% CI -0.06 to 0.38; P = 0.15; 6 studies; 1453 participants, low-certainty evidence). Heterogeneity between studies for cognitive outcomes in infancy and preschool age was moderate and at school age was substantial. Regarding motor function, meta-analysis of 23 studies showed that early developmental interventions may improve motor outcomes in infancy (motor scale DQ: SMD 0.12 SD, 95% CI 0.04 to 0.19; P = 0.003; 23 studies; 2737 participants, low-certainty evidence). At preschool age, the intervention probably did not improve motor outcomes (motor scale: SMD 0.08 SD, 95% CI -0.16 to 0.32; P = 0.53; 3 studies; 264 participants, moderate-certainty evidence). The evidence at school age for both continuous (motor scale: SMD -0.06 SD, 95% CI -0.31 to 0.18; P = 0.61; three studies; 265 participants, low-certainty evidence) and dichotomous outcome measures (low score on Movement Assessment Battery for Children (ABC) : RR 1.04, 95% CI 0.82 to 1.32; P = 0.74; 3 studies; 413 participants, low-certainty evidence) suggests that intervention may not improve motor outcome. The main source of bias was performance bias, where there was a lack of blinding of participants and personnel, which was unavoidable in this type of intervention study. Other biases in some studies included attrition bias where the outcome data were incomplete, and inadequate allocation concealment or selection bias. The GRADE assessment identified a lower certainty of evidence in the cognitive and motor outcomes at school age. Cognitive outcomes at preschool age demonstrated a high certainty due to more consistency and a larger treatment effect.

AUTHORS' CONCLUSIONS

Early developmental intervention programmes for preterm infants probably improve cognitive and motor outcomes during infancy (low-certainty evidence) while, at preschool age, intervention is shown to improve cognitive outcomes (high-certainty evidence). Considerable heterogeneity exists between studies due to variations in aspects of the intervention programmes, the population and outcome measures utilised. Further research is needed to determine which types of early developmental interventions are most effective in improving cognitive and motor outcomes, and in particular to discern whether there is a longer-term benefit from these programmes.

The Association of Nonmodifiable Patient Factors on Antipsychotic Medication use in the Intensive Care Unit

PURPOSE

We investigated the association of age, sex, race, and insurance status on antipsychotic medication use among intensive care unit (ICU) patients.

MATERIALS AND METHODS

Retrospective study of adults admitted to ICUs at a tertiary academic center. Patient characteristics, hospital course, and medication (olanzapine, quetiapine, and haloperidol) data were collected. Logistic regression models evaluated the independent association of age, sex, race, and insurance status on the use of each antipsychotic, adjusting for prespecified covariates.

RESULTS

Of 27,137 encounters identified, 6191 (22.8%) received antipsychotics. Age was significantly associated with the odds of receiving olanzapine (P < .001), quetiapine (P = .001), and haloperidol (P = .0046). Male sex and public insurance status were associated with increased odds of receiving antipsychotics olanzapine, quetiapine, and haloperidol (Male vs Female: OR 1.13, 95% CI [1.04, 1.24], P = .0005; OR 1.22, 95% CI [1.10, 1.34], P = .0001; OR 1.28, 95% CI [1.17, 1.40], P < .0001, respectively; public insurance vs private insurance: OR 1.32, 95% CI [1.20, 1.46], P < .0001; OR 1.21, 95% CI [1.09, 1.34], P = .0004; OR 1.15, 95% CI [1.04, 1.27], P = .0058, respectively). Black race was also associated with a decreased odds of receiving all antipsychotics (olanzapine (P = .0177), quetiapine (P = .004), haloperidol (P = .0041)).

CONCLUSIONS

Age, sex, race, and insurance status were associated with the use of all antipsychotic medications investigated, highlighting the importance of investigating the potential impact of these prescribing decisions on patient outcomes across diverse populations. Recognizing how nonmodifiable patient factors have the potential to influence prescribing practices may be considered an important factor toward optimizing medication regimens.

Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures

Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n  =  389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.

Digital tools for post-discharge surveillance of surgical site infection

AIMS

Conduct a scoping review on the development and use of digital tools for post-discharge surgical site infection surveillance.

DESIGN

Scoping review.

DATA SOURCES

Science Direct, PubMed, Embase, Literatura Latino-Americana e do Caribe em Ciências da Saúde and Cumulative Index to Nursing and Allied Health Literature were searched from 2013 to May 2022. Six intellectual property registries were reviewed from 2013 to 2022.

REVIEW METHODS

The review followed the Joanna Briggs Institute model, and included intellectual property records (applications, prototypes and software) and scientific articles published in any language on the development and/or testing of digital tools for post-discharge surveillance of surgical site infection among surgical patients aged 18 and over.

RESULTS

One intellectual property record and 13 scientific articles were identified, covering 10 digital tools. The intellectual property record was developed and registered by a China educational institution in 2018. The majority of manuscripts were prospective cohort studies and randomized clinical trials, published between 2016 and 2022, and more than half were conducted in the United States. The population included adult patients undergoing cardiac, thoracic, vascular, abdominal, arthroplasty and caesarean surgery. The main functionalities of the digital tools were the previously prepared questionnaire, the attachment of a wound image, the integrated Web system and the evaluation of data by the health team, with post-discharge surgical site infection surveillance time between 14 and 30 days after surgery.

CONCLUSION

Digital tools show promise for the surveillance of surgical site infection, collaborating with the early detection of wound infection.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Mobile technology was favourable for detecting surgical site infections, reducing unnecessary visits to the health service, and increasing patient satisfaction.

IMPACT

Technological advances in the health area open new perspectives for post-discharge surveillance of surgical site infection. WHAT IS ALREADY KNOWN?: There is underreporting of surgical site infections due to difficulties related to traditional methods of post-discharge surveillance. The use of digital tools within surgical site infection surveillance is increasing. Benefits of using digital tools within surgical site infection surveillance have been reported. WHAT HAS THIS STUDY ADDED TO OUR KNOWLEDGE?: This scoping review is one of the first to analyse the development and use of digital tools for post-discharge surveillance of surgical site infection in different countries. The main functionalities of digital tools are: structured questionnaires; attachment of wound images; integrated web systems; and evaluation of data by professionals. The use of mobile technology is favourable for detecting surgical site infections with a reduction in costs from face-to-face consultations and increased patient satisfaction. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Healthcare providers can successfully use digital tools for surgical site infection post-discharge surveillance. Remote monitoring can reduce unnecessary patient visits to healthcare facilities. Policy makers can study how to implement digital platforms for remote patient monitoring.

REPORTING METHOD

PRISMA statement for Scoping Reviews (PRISMA-ScR).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

TRIAL AND PROTOCOL REGISTRATION

The study protocol was registered in the OSF (https://doi.org/10.17605/OSF.IO/BA8D6).

Essential elements nurses have to address to promote a safe discharge in paediatrics: A systematic review and narrative synthesis

AIM

The aim of the study was to synthesize the evidence on the essential elements, nurses must address when they perform therapeutic education to patients and their caregivers to promote a safe paediatric hospital-to-home discharge.

DESIGN

A systematic review and narrative synthesis.

METHODS

The search strategy identifies studies published between 2016 and 2023. The quality of the included studies was assessed using the Critical Appraisal Skills Programme checklists. The protocol of this review was not registered. A search of three electronic databases (PubMed, CINAHL and Web of Science) and a search in the reference lists of the included studies was conducted in February 2021 and June 2023.

RESULTS

Fifteen studies met the inclusion criteria. The essential elements identified are grouped into the following topics: emergency management, physiological needs, medical device and medications management, long-term management and short-term management. Nurses have a critical role in ensuring patient safety and quality of care, and the nurses' competence makes the difference in the discharge's related outcomes. Our results can help the nursing profession implement comprehensive discharge projects. Our results support the improvement of nurse-led paediatric discharge programmes. Nurse managers can identify the grey areas of therapeutic education provided in their units and work for their improvement. Following the implementation of therapeutic education on these topics, measuring the discharge's related outcomes could be interesting. This study addresses the problem of managing a safe and efficient nurse-led discharge in a paediatric setting. It presents evidence on the essential elements to promote a safe paediatric discharge at home. These could impact nursing practice by using them to implement project and discharge pathways. We have adhered to relevant EQUATOR guidelines-PRISMA guidelines for reporting systematic review. No patients, service users, caregivers or public members were involved in this study due to its nature (systematic review).

Significance of Chronic Kidney Disease on Morbidity and Mortality in Hospitalized Patients With COVID-19

Background

Patients with comorbid illnesses are at risk for worse outcomes with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19). Our research examined patients with chronic kidney disease (CKD) to establish whether it remains an independent risk factor for mortality and morbidity in patients with COVID-19.

Methods

We conducted a retrospective cohort study using an electronic patient database in 2020. An observational dataset from 149 hospitals comprising a United States-based health system (HCA Healthcare) was analyzed. Hospitalized patients (N=11 086), aged 18 and above, with a COVID-19 polymerase chain reaction positive result between January 1, 2020, and September 1, 2020, were included in the initial data set.Primary outcomes were in-hospital death or discharge to hospice in patients with COVID-19. Secondary outcomes were individual components of the primary outcome including intensive care unit (ICU) admission, ventilator dependency, development of acute kidney injury (AKI), and in-hospital death. Baseline patient characteristics were recorded, including demographic variables and comorbidities.

Results

A total of 11 086 patients were included in the analysis. The study group included patients with CKD (5543 patients). Patients in the control group (5543 patients) were propensity matched for age, race, sex, and ethnicity. The primary outcome of in-hospital death or discharge to hospice was observed in 20.96% of patients with CKD compared to 11.91% of the control group with an odds ratio of 1.58 (confidence interval 1.37-1.80). ICU admission was required for 37.20% of patients in the CKD group and 21.63% of patients in the control group (P < .001). Ventilator dependency was found in 14.41% of patients in the CKD group and 8.59% of patients in the control group (P < .01). Development of AKI was seen in 5.65% of patients in the CKD group and 2.90% of patients in the control group (P < .01). A logistic regression model confirmed an independent association between underlying CKD and in-hospital death or discharge to hospice in patients with COVID-19.

Conclusion

Our study confirms an independent association between underlying CKD and poor outcomes among hospitalized patients with COVID-19, including in-hospital death or discharge to hospice.

Evaluation of Delayed Effective Discharge for Non-Medical Reasons in Patients Admitted to Acute Care Hospitals in Spain: A Scoping Review

Delayed discharge for non-clinical reasons is defined as a period of stay that continues after a patient has been deemed medically fit to leave the hospital but is unable to do so for non-medical reasons. This circumstance overburdens the healthcare system and constitutes a major problem for healthcare systems and the patients themselves in this situation. The aim of this study was to evaluate the delay in effective discharge for non-medical reasons for patients admitted to acute care hospitals in Spain. A scoping review followed the Joanna Briggs Institute methodology guidelines to search for and synthesize studies published between 2019 and 2022. To identify potentially relevant documents, the following bibliographic databases were searched: EMBASE, CINAHL and MEDLINE. For the search, we used free terms («delayed discharges», «discharge delays», «bed-blocking», «timely discharge», «unnecessary days» and «inappropriate stays»). Quantitative or qualitative studies published in scientific journals on delayed effective discharge for non-medical reasons for patients admitted to a hospital for any health issue of medical or surgical origin were selected. Information collection of the documents was performed using a structured datasheet specifically developed by the authors. The initial search strategy identified a total of 124 references, which were successively screened to a final selection of 13 studies. To conclude, delayed discharge from a hospital for non-clinical reasons is a multifactorial problem. This may be due to factors internal or external to the hospital, as well as personal factors. The main causes of the delay were similar among the studies found, as were the clinical characteristics of the patients, most of whom were elderly, frail and more dependent due to declining functional capacities. Further studies addressing the socio-familial characteristics of the patients and the perspective of the patient and families would be necessary.

Early Ambulation Shortened the Length of Hospital Stay in ICU Patients after Abdominal Surgery

The optimal time to ambulation remains unclear for intensive care unit (ICU) patients following abdominal surgery. While previous studies have explored various mobilization techniques, a direct comparison between ambulation and other early mobilization methods is lacking. Additionally, the impact of time to ambulation on complications and disuse syndrome prevention requires further investigation. This study aimed to identify the optimal time to ambulation for ICU patients after abdominal surgery and considered its potential influence on complications and disuse syndrome. We examined the relationship between time to ambulation and hospital length of stay (LOS). Patients were categorized into the nondelayed (discharge within the protocol time) and delayed (discharge later than expected) groups. Data regarding preoperative functioning, postoperative complications, and time to discharge were retrospectively collected and analyzed. Of the 274 postsurgical patients managed in the ICU at our hospital between 2018 and 2020, 188 were included. Time to ambulation was a significant prognostic factor for both groups, even after adjusting for operative time and complications. The area under the curve was 0.72, and the cutoff value for time to ambulation was 22 h (sensitivity, 68%; specificity, 77%). A correlation between time to ambulation and complications was observed, with both impacting the hospital LOS (model 1: p < 0.01, r = 0.22; model 2: p < 0.01, r = 0.29). Specific cutoff values for time to ambulation will contribute to better surgical protocols.

Interprofessional actions in responsible discharge: contributions to transition and continuity of care

OBJECTIVE

To analyze the interprofessional team's perception of the actions carried out by means of responsible hospital discharge, and their contribution to improving the transition and continuity of patient care.

METHODS

A qualitative study was carried out in two hospitalization units, in October - November 2020, interviewing health professionals from a teaching hospital in the state of São Paulo. The reports were transcribed and subjected to thematic content analysis.

RESULTS

Twelve professionals participated (doctor, nurse, physiotherapist, nutritionist, speech therapist and social worker) and three thematic categories emerged from the interviews: 1. informational continuity in responsible discharge; 2. interaction between professionals and services for the transition of care; and 3. workload management for better transition and continuity of care.

CONCLUSION

The team recognized interprofessional advances and challenges in responsible discharge related to the informational and relational continuity of patient care and highlighted the (over)workload as an unfavorable aspect in the transition process, generating impacts for patients, professionals and health services.

Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention

BACKGROUND

Discharges against medical advice (DAMA) increase the risk of death.

METHODS

We retrieved DAMA from five hospitals within a large health system and reviewed 10% of DAMA from the academic site between 2016 and 2021.

RESULTS

DAMA increased at the onset of the pandemic. Patients who discharged AMA multiple times accounted for a third of all DAMA. Detailed review was completed for 278 patients who discharged AMA from the academic site. In this sample, women comprised 52% of those who discharged AMA multiple times. Relative to the proportion of all discharges from the academic site during the study period, Black patients were overrepresented among DAMA (21% vs. 34%, p < .05). Patients with multiple AMA discharges were younger, more likely to be unmarried, or have substance use disorders (SUD) than those who discharged AMA once. The most common reason for requesting premature discharge noted in n = 77, 28% of instances was related to patient obligations outside the hospital. Hospital policies and procedures contributed in n = 29, 10% of instances. Reasons for requesting premature discharge and documentation of key safety processes were similar by gender and race however the sample may be underpowered to detect differences. Capacity was evaluated in 109 (39%). Among those who consumed alcohol (n = 81 (29%)) or had SUDs (n = 112 (40%)), information on the amount or timing of last use was missing in n = 39 (48%) and n = 74 (66%), respectively. Critical tools to manage illness were provided in 45 (16%) of DAMA reviewed.

CONCLUSIONS

Drivers of AMA discharge may differ by AMA discharge frequency. Recognition of the common reasons for requesting premature discharge may help destigmatize AMA discharges and also identifies early assessments by social work colleagues as an important prevention strategy. Opportunities also exist in anticipating and preventing withdrawal symptoms and in revising hospital practices that contribute to DAMA.

Discharge transitional care programme for older adults after hip fracture surgery: a quasi-experimental study

Background

Hip fractures require extended periods of recovery and rehabilitation, subjecting older adults to discontinuous care. Discharge transition is a critical point of heightened vulnerability for older adults.

Aims

This study aimed to evaluate the effectiveness of a transitional care programme on the physical functions and quality of life (QOL) of older adults after hip fracture surgery.

Methods

Seventy-five older adults were assessed from pre-discharge to 6 weeks after hip surgery, and their physical functions, including walking status and activities of daily living, were measured. The QOL was measured using the European Quality of life-5 Dimensions-5 Levels (EQ 5D 5L).

Results

There was a significant strong effect of time (B = 10.565; 95% CI = 2.584-18.547; p = 0.009) on the EuroQol Visual Analog Scale (EQ-VAS) for the experimental group. However, there were no significant effects of time on physical functions and EQ-5D-5L scores.

Conclusions

The discharge transitional care programme improved the EQ-VAS of older adults following hip fracture surgery 6 weeks post-surgery. However, there were no significant differences in physical functions and EQ-5D between the groups.

Role of C-Reactive Protein, White Blood Cell Counts, and Serum Glucose Levels as Early Predictors of Infectious Complications After Laparoscopic Colorectal Surgery for Colorectal Cancer

BACKGROUND

The early detection of infectious complications of colorectal surgery leads to better patient outcomes. This study aimed to assess the role of C-reactive protein (CRP), white blood cell count (WBC), and serum glucose in the early prediction of infectious complications of laparoscopic colorectal surgery.

METHODS

Patients who underwent laparoscopic colorectal surgery were included and stratified into two groups: infectious complication (IC) or no infectious complication (non-IC). Serum levels were measured on postoperative days (PODs) 2 and 4.

RESULTS

Analysis of 224 patients (IC group: 27, Non-IC group: 197) revealed higher CRP levels in IC group on POD 2 (P = .001). On POD 4, CRP levels and WBC counts were higher in IC group (P<.001, P = .011, respectively). The area under the curve (AUC) of the receiver operating characteristic (ROC) for CRP on PODs 2 and 4 were .743 and .907, respectively, and for WBC on POD 4 was .687. The cut-offs of CRP on PODs 2 and 4 were 156.2 mg/L and 91.3 mg/L, respectively; the cut-off of WBC was 7,220 cells/mm3. Sensitivity of CRP level ≥91.3 mg/L or WBC count ≥7,220 cells/mm3 was 96.3%; (cf. 88.9% for CRP alone), and specificity of CRP level ≥91.3 mg/L and WBC count ≥7,220 cells/mm3 was 93.4% (cf. 82.2% for CRP alone).

DISCUSSION

The CRP level on postoperative day (POD) 2 and the combined CRP and WBC on POD 4 were meaningful in predicting infectious complications after laparoscopic colorectal surgery. However, serum glucose levels had a low predictive value for infectious complications.

Thoughts and concerns of patients at hospital discharge after lumbar spine surgery. A qualitative study

PURPOSE

The increased rate of surgical interventions point to the necessity to investigate the patient's experience from a biopsychosocial perspective. The aim of this study was to investigate the thoughts and concerns of patients undergoing spinal surgery for lumbar degenerative disease at the time of their discharge from hospital.

METHODS

Semi-structured interviews were conducted with 28 patients. The questions investigated possible concerns associated to discharging them home. A content analysis was performed by a multidisciplinary group to identify the main themes that emerged from the interviews.

RESULTS

The patients were satisfied with the surgeons' preoperative explanations and description of expected prognosis. However, they were disappointed with the lack of information at hospital discharge, in particular regarding practical and behavioral recommendations. The patients expressed clear concerns about being left alone to deal with possible complications or difficulties they may encounter when returning home.

CONCLUSION

This study underlined the patients' need for a comprehensive psychological guidance and possibly a person of reference during the post-operative process. Discussing discharge with the patient was emphasized as an important issue to improve patients' compliance to the recovery process itself. Putting these elements into practice should help spine surgeons to manage better hospital discharge.IMPLICATIONS FOR REHABILITATIONA comprehensive discussion with the patient at the time of hospital discharge is clearly stressed as an important issue to improve patients' adherence to the recovery process.The patients complained of a lack of information when returning home, in particular regarding practical and behavioral recommendations.The patients expressed clear concerns about possible complications or difficulties they may encounter when returning home and they expressed their need to know whom they can contact for help if needed.A better understanding of the thoughts and concerns of patients undergoing spinal surgery at the time of their discharge from hospital should help spine surgeons to improve the management of hospital discharge and the post-operative recovery.

Physical functioning factors predicting a return home after stroke rehabilitation: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis sought to identify the physical functioning factors associated with home discharge after inpatient stroke rehabilitation.

DATA SOURCES

A search of PubMed, Embase, CINHAL, The Cochrane Library (Trials), Web of Science, and PEDro were conducted up until May 2023.

METHODS

Two independent reviewers selected studies for population (patients with stroke), predictive factors (physical functioning), outcome (discharge destination), setting (inpatient rehabilitation), and study designs (observational and experimental studies). Predictive factors were identified among assessments of the "body function" and "activity" components of the International Classification of Functioning. Methodological quality was assessed with the Newcastle-Ottawa Scale. The findings used quantitative and narrative syntheses. Meta-analyses were performed with the inverse variance method and the random-effects model using included studies with sufficient data.

RESULTS

Forty-five studies were included with 204,787 participants. Included studies assessed the association of independence in activities of daily living, walking, rolling, transferring, and balance on admission with a probability of returning home. Motor (odds ratio = 1.23, 95% confidence interval: 1.12-1.35, p < .001) and total (odds ratio = 1.34, 95% confidence interval: 1.14-1.57, p < .001) Functional Independence Measure scores on admission were significantly associated with home discharge in meta-analyses. Additionally, included studies showed that independence in motor activities, such as sitting, transferring, and walking, and scores above thresholds for the Functional Independence Measure and Berg Balance Scale on admission were associated with discharge destination.

CONCLUSION

This review showed that higher independence in activities of daily living on admission is associated with home discharge after inpatient stroke rehabilitation.

Diagnostic utility and outcomes of inpatient investigations for syncope in a regional setting

BACKGROUND

Syncope is a common presentation to the emergency department with a wide spectrum of aetiology. The identification of the underlying cause can be diagnostically challenging, as are the choice of investigations and the decision for inpatient versus outpatient disposition.

AIMS

This study aimed to evaluate the aetiology of syncope as documented, the diagnostic yield of inpatient investigations and outcomes for adult patients admitted for syncope.

METHODS

A single-centred, retrospective cohort study was conducted in adult patients admitted for syncope within a 2-year period. A total of 386 patients were identified after exclusion. Information regarding syncope aetiology, investigations and outcomes were established via chart review of electronic records.

RESULTS

The most common cause of syncope was neural-mediated (43%), followed by orthostatic (36.5%) and cardiogenic (20.5%). The investigations performed in order of frequency included: telemetry electrocardiogram (ECG) (75.4%), computed tomography head non-contrast (58.8%), transthoracic echocardiogram (TTE) (20.2%), computed tomography pulmonary angiogram (CTPA) (6.5%), MR brain (3.9%), electroencephalogram (1.3%) and carotid ultrasound (0.3%). Telemetry ECG, TTE and CTPA led to the diagnosis of syncope in a minority of patients only. As a result, 17.5% of patients had a new intervention on discharge, 5.4% were readmitted for syncope and 9.6% of patients died.

CONCLUSIONS

In the context of the inpatient evaluation of syncope, this study supports the use of telemetry ECG and TTE. Neuroimaging demonstrates a low diagnostic yield for the cause of syncope, but it may have a role to play in excluding other pathologies. Our study does not support the routine use of CTPA, EEG or carotid ultrasound in the evaluation of syncope.

Continuity of care for patients recovering from Covid-19 under the angle of clinical management principles

OBJECTIVE

To analyze the strategies used by nurses at a university hospital to ensure continuity of care at hospital discharge for patients recovered from Covid-19, under the angle of the principles of clinical management.

METHOD

A descriptive study with a qualitative approach, carried out with seven nurses on duty in the medical and gynecology/obstetrics clinics of a university hospital in the Midwest region of the country. The data was processed using IRaMuTeQ software and analyzed using Content Analysis.

RESULTS

The data resulted in five classes by the Descending Hierarchical Classification (DHC), which made up two categories: "Practices developed by nurses for continuity of care in the hospital environment" and "Continuity of care during discharge to the home". The strategies used by the nurses were: daily care systematized in the nursing process and guidance both for preparation and for the day of discharge.

CONCLUSION

The absence of an institutional protocol for safe discharge, as well as the position of nurse coordinator to manage the discharge of patients with Covid-19, can compromise the continuity of care for these patients.

Transition and continuity of care after hospital discharge for COVID-19 survivors

OBJECTIVE

To assess care transition quality and compare it with the clinical characteristics and continuity of care after hospital discharge of COVID-19 survivors.

METHOD

This is a descriptive, observational and cross-sectional study, carried out with 300 patients with COVID-19 who were discharged from a hospital in southern Brazil. The Care Transitions Measure (CTM-15) and question guide about symptoms, difficulties and use of health services after discharge were used. Student's t-test, Pearson and Spearman correlation were used.

RESULTS

The mean score for care transition quality was 74.2 (±18.2). Factors associated with higher quality were receiving care in intensive care (p = 0.001), using non-invasive mechanical ventilation (p = 0.05), using vasopressors (p = 0.027) and having an appointment at the hospital after discharge (p = 0.014). Positive correlated factors were length of stay (p = 0.017), and negative factors were post-discharge symptoms of fatigue (p = 0.001), weakness (p = 0.008), difficulty doing moderate activities (p = 0.003) and how difficult recovery is (p = 0.003).

CONCLUSION

Most participants had a satisfactory perception of care transition. However, aspects such as care plans, referrals and follow-up after hospital discharge require improvements.

Ethical considerations in evaluating discharge readiness from the intensive care unit

Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients' readiness can conflict with perceptions of what readiness means for patients, families, and healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families.

Applying Lean Healthcare in the hospitalization and patient discharge process: an integrative review

OBJECTIVES

to identify scientific evidence regarding the use of Lean Healthcare approach in the hospitalization and patient discharge process.

METHODS

this is an Integrative Review conducted in the PubMed, LILACS, SCOPUS, CINAHL, Web of Science, and Embase databases.

RESULTS

out of 904 records identified, three were included in this review. The studies demonstrated that when applied to discharge planning, the Lean philosophy brings favorable results, promoting improvements in the communication process, as well as assisting in workflow organization, with a reduction in length of stay and improvement in the quality of care.

FINAL CONSIDERATIONS

although the Lean methodology presents positive results, it is considered that the application of the philosophy in healthcare institutions is still not sustainable, as it is often restricted to specific departments or services. Thus, to maximize the success of implementation, the Lean philosophy needs to be incorporated into the organizational culture, representing the greatest challenge.

Trends in incidence of ischaemic stroke in people with and without diabetes in Ireland 2005-2015

AIMS

We aim to describe the epidemiology of ischaemic stroke and in-hospital mortality associated with stroke among men and women with and without diabetes from 2005 to 2015.

METHODS

Secondary data analysis of national hospital discharge data from the Hospital Inpatient Enquiry database. Stroke incidence and in-hospital mortality rates in people with and without diabetes were calculated. Poisson regression models were used to estimate the incidence rate ratio (IRR) and assess trends over time.

RESULTS

The age-adjusted incidence of stroke was twice as high in people with diabetes compared to those without diabetes (men IRR 2.0 [95% CI 1.95-2.06] and women IRR 2.2 [95% CI 2.12-2.27]). The incidence of ischaemic stroke decreased by an average 1.7% per year in men with diabetes and 3.3% per year in women with diabetes. In people without diabetes, the average annual reduction was smaller (0.2% per year in men and 1% per year in women). In-hospital mortality associated with admission with ischaemic stroke was approximately twice as high in those with diabetes compared to those without diabetes among men [IRR 1.81 (1.67-1.97)] and women [IRR 2 (95% CI 1.84-2.18)].

CONCLUSION

Despite decreases in incidence of ischaemic stroke and associated in-hospital mortality, there remains a twofold increased risk of ischaemic stroke and mortality in people with diabetes. Therefore, priority must be given to management of risk factors for ischaemic stroke in people with diabetes as well as continued development of targeted stroke prevention strategies.

Effects of a telehealth program for wound healing promotion on the wound healing level in patients with diabetes undergoing coronary artery bypass graft surgery: A randomized controlled trial

Background

Patients with diabetes undergoing coronary artery bypass graft (CABG) are at risk of delayed wound healing. The telehealth program for wound healing promotion (TPWHP) was developed to improve wound healing in patients with diabetes undergoing CABG in a university hospital.

Objective

This study aimed to examine the effects of the TPWHP on the healing of the sternal wound and saphenous vein graft (SVG) donor site in patients with diabetes undergoing CABG.

Methods

In this randomized controlled trial, the participants were randomly assigned to the intervention (n = 30) and control (n = 30) groups. The control group received routine nursing care, whereas the intervention group received routine nursing care along with the TPWHP, which provides education and wound monitoring using multimedia and a surgical wound care booklet and monitors the wound through the LINE application on a smartphone after hospital discharge. Data were collected from June to November 2020 at two university hospitals in Bangkok, Thailand, using the demographic and health-related data form and the Thai wound assessment inventory (WAI). Data were analyzed using the Chi-squared, Fisher's exact, and Mann-Whitney U tests.

Results

The intervention group had significantly lower mean scores-indicating favorable wound healing-for SVG donor site wound healing level than the control group on days 14-21 after surgery (p = 0.012, mean = 0.58 ± 0.54 and 1.08 ± 0.82, respectively). No significant intergroup difference was observed in terms of the sternal wound healing level (p = 0.126); however, the intervention group showed lower mean scores-indicating good wound healing-than the control group.

Conclusion

The TPWHP promotes effective wound healing of the SVG donor site; however, its efficacy on sternal wound healing was uncertain. Therefore, nurses should implement the TPWHP in collaboration with a multidisciplinary team to improve wound healing after hospital discharge.

Trial registration

Thai Clinical Trials Registry (TCTR20211112002).

Interdisciplinary Shadowing and Case Discussion Improve Medical Students' Self-Efficacy and Attitude Toward Discharge Planning

Background

The Discharge Planning Curriculum (DPC) is a 4-hour course for penultimate-year medical students at a tertiary teaching hospital in Taiwan. The course begins with a 30-minute introduction, followed by the students shadowing discharge planning case managers as they visit patients on the wards. After patient visits, the students engaged in a 1-hour case discussion. Our research assessed the effectiveness of the DPC for medical students.

Methods

This mixed methods study recruited medical students participating in family medicine rotations between October 2017 and May 2018. To determine the impact of the DPC, we quantitatively analyzed questionnaire responses to measure changes in self-efficacy, attitude toward discharge planning, and course satisfaction before and after completing the DPC. Additionally, we conducted qualitative focus group interviews to gain insight into the students' learning experiences and applied thematic analysis to the interview data.

Results

Our study found two quantitative results: 1) The DPC significantly improved self-efficacy and attitude toward discharge planning (p < 0.001). 2) The medical students acquired knowledge about home care, assistive device application, long-term care facility referral, home rehabilitation, and home care services, and more than 95% of the students reported being satisfied with the course. In addition, the focus group interviews revealed that medical students learned several aspects of discharge planning through the curriculum, including an understanding of various aspects of discharge planning through the curriculum, the importance of early discharge planning, the roles of doctors and case managers, and the challenges faced in the process.

Conclusion

The DPC helped medical students understand different team members' roles in discharge planning and appreciate the challenges that case managers face in this process. The DPC improved medical students' attitudes toward discharge planning. The curriculum can be a valuable tool in training future healthcare providers in effective transitional care.

Transition of care of patients with chronic diseases and its relation with clinical and sociodemographic characteristics

OBJECTIVE

evaluate the transition of care from the perspective of people living with chronic diseases and identify its relation with clinical and sociodemographic characteristics.

METHOD

cross-sectional study with 487 patients who were discharged from a hospital. Clinical and sociodemographic characterization instruments were used, as well as the Care Transitions Measure-15, which measures Preparation for self-management, Secured preferences, Understanding about medications and Care plan factors. Descriptive and inferential statistical analysis.

RESULTS

the transition of care was satisfactory (76.8±10.4). Average of the factors: Preparation for self-management (82.2±10.8), Secured preferences (84.7±14.3), Understanding about medications (75.7±13.7) and Care plan (64.5±13.2). Female patients had a higher average in the understanding about medications factor. Whites and residents in the urban area better evaluated the Care plan factor. The highest mean was observed for the Secured preferences factor (84.7±14.3) and the lowest for the Care plan factor (64.5±13.2). In all factors, significant differences were found in the variables (surgical patient, carrying clinical artifacts and not being hospitalized for COVID-19). Patients hospitalized for up to five days showed statistical difference in Preparation for self-management and Understanding about medications factors. In patients who were not readmitted within 30 days of discharge, Preparation for self-management was better. The better the Preparation for self-management, the lower the 30-day readmission rates.

CONCLUSION

in patients living with chronic diseases, sociodemographic and clinical variables are associated with the transition of care. Patients who better evaluated preparation for self-management had fewer readmissions within 30 days. (1) Brazilian study that evaluated the transition of care of patients with CNCDs. (2) Women had a higher average in the understanding about medications factor. (3) Whites and residents in the urban area better evaluated the care plan. (4) Better preparation for self-management reduces length of stay and readmissions. (5) Better preparation for understanding about medications reduces hospitalization time.

Transition of care in post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil

OBJECTIVE

To analyze the transition of care for post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil.

METHODS

Quantitative, cross-sectional, descriptive, and analytical study carried out between 2020 and 2021. The sample had 78 patients. Data collection took place by telephone with the support of a sociodemographic questionnaire and the care transition assessment instrument (Care Transitions Measure).

RESULTS

The average length of stay was 24.04 days. The average score for care transition was 71.68 (±11.71). "Self-management training" and "Understanding of medications" had higher averages, 75.15 (±13.76) and 74.10 (±16.20).

CONCLUSIONS

The average length of stay was 24.04 days. The average score for care transition was 71.68 (±11.71). "Self-management training" and "Understanding of medications" had higher averages, 75.15 (±13.76) and 74.10 (±16.20).

The role of collaborative decision-making in discharge planning: Perspectives from patients, family members and health professionals

AIM

To explore discharge planning with a range of key stakeholders in subacute care, including consumers.

DESIGN

Qualitative descriptive study.

METHODS

Patients (n = 16), families (n = 16), clinicians (n = 17) and managers (n = 12) participated in semi-structured interviews or focus groups. Following transcription, data were analysed thematically.

RESULTS

The overarching facilitator of effective discharge planning was collaborative communication, leading to shared expectations by all stakeholders. Collaborative communication was underpinned by four key themes: patient- and family-centred decision-making, early goal setting, strong inter- and intra-disciplinary teamwork, and robust patient/family education.

CONCLUSION

Effective planning for discharge from subacute care is enabled by shared expectations and collaborative communication between key stakeholders.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Effective discharge planning processes are underpinned by effective inter- and intra-disciplinary teamwork. Healthcare networks should foster environments that promote effective communication between and within multidisciplinary team members as well as with patients and their families. Applying these principles to discharge planning may assist in reducing length of stays and rates of preventable readmissions post-discharge.

IMPACT

This study addressed a lack of knowledge about effective discharge planning in Australian subacute care. It found that collaborative communication between stakeholders was an overarching facilitator of effective discharge planning. This finding impacts subacute service design and professional education.

REPORTING METHOD

COREQ guidelines were followed in reporting this study.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution in the design, data analysis or preparation of the manuscript.

Intensive glucose control in critically ill adults: a protocol for a systematic review and individual patient data meta-analysis

OBJECTIVE

The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults.

DATA SOURCES

MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published trial-level data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available.

METHODS

Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of ≤ 120mg/dL (≤ 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge.

PRIMARY ENDPOINT

In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used.

DISCUSSION

This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?'Protocol version 0.4 - 06/26/2023PROSPERO registration:CRD42021278869.

Inpatient Neurology Deaths and Factors Associated With Discharge to Hospice

Background and Purpose

The Neurology Mortality Review Committee at our institution identified variability in location of death for patients on our inpatient neurology services. Hospice may increase the number of patients dying in their preferred locations. This study aimed to characterize patients who die on inpatient neurology services and explore barriers to discharge to hospice.

Methods

This retrospective study was completed at a single, quaternary care medical center that is a Level I Trauma Center and Comprehensive Stroke Center. Patients discharged by an inpatient neurology service between 6/2019-1/2021 were identified and electronic medical record review was performed on patients who died in the hospital and who were discharged to hospice.

Results

69 inpatient deaths and 74 discharges to hospice occurred during the study period. Of the 69 deaths, 54 occurred following withdrawal of life sustaining treatment (WLST), of which 14 had a referral to hospice placed. There were 88 "hospice-referred" patients and 40 "hospice-eligible" patients. Hospice-referred patients were less likely to require the intensive care unit than hospice-eligible patients. Hospice-referred patients had their code status changed to Do Not Intubate earlier and were more likely to have advanced directives available.

Conclusion

Our data highlight opportunities for further research to improve discharge to hospice including interhospital transfers, advanced directives, earlier goals of care discussions, palliative care consultations, and increased hospice bed availability. Importantly, it highlights the limitations of using in-hospital mortality as a quality indicator in this patient population.

Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in Skilled Nursing Facilities

BACKGROUND AND PURPOSE

Physical and occupational therapy practices in skilled nursing facilities (SNFs) were greatly impacted by the 2019 Medicare Patient-Driven Payment Model (PDPM). Under the PDPM, the practice of multiparticipant therapy-treating more than one patient per therapy provider per session-increased in SNFs, but it is unknown how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. This cross-sectional study establishes baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data.

METHODS

We used Minimum Data Set assessments from all short-term Medicare fee-for-service SNF stays in 2018. Using generalized mixed-effects logistic regression adjusted for therapy volume and patient factors, we examined associations between the proportion of minutes of physical and occupational therapy that were received as multiparticipant sessions during the SNF stay and 2 outcomes: community discharge and functional improvement. Multiparticipant therapy minutes as a proportion of total therapy time were categorized as none, low (below the median of 5%), medium (median to <25%), and high (≥25%) to reflect the 25% multiparticipant therapy limit required by the PDPM.

RESULTS AND DISCUSSION

We included 901 544 patients with complete data for functional improvement and 912 996 for the discharge outcome. Compared with patients receiving no multiparticipant therapy, adjusted models found small positive associations between low and medium multiparticipant therapy levels and outcomes. Patients receiving low levels of multiparticipant therapy had 14% higher odds of improving in function (95% CI 1.09-1.19) and 10% higher odds of community discharge (95% CI 1.05-1.15). Patients receiving medium levels of multiparticipant therapy had 18% higher odds of functional improvement (95% CI 1.13-1.24) and 44% higher odds of community discharge (95% CI 1.34-1.55). However, associations disappeared with high levels of multiparticipant therapy.

CONCLUSIONS

Prior to the PDPM, providing up to 25% multiparticipant therapy was an efficient strategy for SNFs that may have also benefitted patients. As positive associations disappeared with high levels (≥25%) of multiparticipant therapy, it may be best to continue delivering the majority of therapy in SNFs as individualized treatment.

Post-discharge follow-up system in psychiatric patients: A case study of Farabi Hospital in Isfahan

BACKGROUND

Mental illness is one of the most common problems in human societies and the continuation of care and post-discharge follow-up. This study was conducted to define a post-discharge follow-up framework for Farabi Hospital in Isfahan.

MATERIAL AND METHODS

This was a multistage study, including, interviews literature review, and focus group discussions. Participants included 18 purposefully selected nurses, physicians, and managers, directly involved in the discharge process of Farabi Hospital in Isfahan. The interviews were semi-structured. Data were organized using MAXQDA10 software. The initial framework was set through the extraction of semantic main and secondary codes. The framework was finalized through three several focus group discussion sessions.

RESULTS

Results included of 17 sub-categories and seven main categories as "education," organizational arrangement," "team-building," "patient and family participation and trust," "engaging some supportive institutions of community," "process management" and "information management."

CONCLUSIONS

To implement a post-discharge follow-up system for psychiatric patients in Farabi Hospital of Isfahan must be concentrated to patient and family education, team building, organizational arrangements, participation, and trust of patients and family, while engaging community health centers and notice to information and management and process management.

Impact of standardized, language-concordant hospital discharge instructions on postdischarge medication questions

Written instructions improve patient comprehension of discharge instructions but are often provided only in English even for patients with a non-English language preference (NELP). We implemented standardized written discharge instructions in English, Spanish, and Chinese for hospital medicine patients at an urban academic medical center. Using an interrupted time series analysis, we assessed the impact on medication-related postdischarge questions for patients with English, Spanish, or Chinese language preferences. Of 4013 patients, ∼15% had NELP. Preintervention, Chinese-preferring patients had a 5.6 percentage point higher probability of questions (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI]: 1.08, 2.21) compared to English-preferring patients; Spanish-preferring and English-preferring patients had similar rates of questions. Postintervention, English-preferring and Spanish-preferring patients had no significant change; Chinese-preferring patients had a significant 10.9 percentage point decrease in the probability of questions (aOR = 0.38, 95% CI: 0.21, 0.69) thereby closing the disparity. Language-concordant written discharge instructions may reduce disparities in medication-related postdischarge questions for patients with NELP.

Safeguarding survival: Older persons with multiple chronic conditions' unplanned readmission experiences: A mixed methods systematic review

AIMS AND OBJECTIVES

The aim of this study was to create a holistic understanding of the psychosocial processes of older persons with multiple chronic conditions' experience with unplanned readmission experiences within 30 days of discharge home and identify factors influencing these psychosocial processes.

DESIGN

Mixed methods systematic review.

DATA SOURCES

Six electronic databases (Ovid MEDLINE (R) All 1946-present, Scopus, CINAHL, Embase, PsychINFO and Web of Science).

REVIEW METHODS

Peer-reviewed articles published between 2010 and 2021 and addressed study aims (n = 6116) were screened. Studies were categorised by method: qualitative and quantitative. Qualitative data synthesis used a meta-synthesis approach and applied thematic analysis. Quantitative data synthesis used vote counting. Data (qualitative and quantitative) were integrated through aggregation and configuration.

RESULTS

Ten articles (n = 5 qualitative; n = 5 quantitative) were included. 'Safeguarding survival' described older persons' unplanned readmission experience. Older persons experienced three psychosocial processes: identifying missing pieces of care, reaching for lifelines and feeling unsafe. Factors influencing these psychosocial processes included chronic conditions and discharge diagnosis, increased assistance with functional needs, lack of discharge planning, lack of support, increased intensity of symptoms and previous hospital readmission experiences.

CONCLUSIONS

Older persons felt more unsafe as their symptoms increased in intensity and unmanageability. Unplanned readmission was an action older persons required to safeguard their recovery and survival.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a critical role in assessing and addressing factors that influence older persons' unplanned readmission. Identifying older persons' knowledge about chronic conditions, discharge planning, support (caregivers and community services), changes in functional needs, intensity of symptoms and past readmission experiences may prepare older persons to cope with their return home. Focusing on their health-care needs across the continuum of care (community, home and hospital) will mitigate the risks for unplanned readmission within 30 days of discharge.

REPORTING METHOD

PRISMA guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution due to design.