Key Points
Question
What is the effect of adding structured nurse assessment of patient readiness for discharge to standard medical-surgical unit discharge practices on 30-day return to hospital?
Findings
In this multisite cluster randomized clinical trial, when patient self-assessments were combined with readiness assessment by nurses, high-readmission units showed a reduction in 30-day hospital returns. Mixed results were observed for nurse assessments only and for low-readmission units.
Meaning
Adding a structured discharge readiness assessment by the discharging nurse that includes patient self-assessment to standard practice for hospital discharge may reduce readmissions and emergency department or observation visits.
The Consolidated Framework for Implementation Research guided formative evaluation of the implementation of a redesigned interprofessional team rounding process. The purpose of the redesigned process was to improve health team communication about hospital discharge. Themes emerging from interviews of patients, nurses, and providers revealed the inherent value and positive characteristics of the new process, but also workflow, team hierarchy, and process challenges to successful implementation. The evaluation identified actionable recommendations for modifying the implementation process.
Background
Promoting continuity of nurse assignment during discharge care has the potential to increase patient readiness for discharge—which has been associated with fewer readmissions and emergency department visits. The few studies that examined nurse continuity during acute care hospitalizations did not focus on discharge or postdischarge outcomes.
Objectives
The aim of this research was to examine the association of continuity in nurse assignment to patients prior to hospital discharge with return to hospital (readmission and emergency department or observation visits), including exploration of the mediating pathway through patient readiness for discharge and moderating effects of unit environment and unit nurse characteristics.
Methods
In a sample of 18,203 adult, medical–surgical patients from 31 Magnet hospitals, a correlational path analysis design was used in a secondary analysis to evaluate the effect of nurse continuity on readmissions and emergency department or observation visits within 30 days after hospital discharge. The mediating pathway through discharge readiness measured by patient self-report and nurse assessments was also assessed. Moderating effects of unit environment and nursing characteristics were examined across quartiles of unit environment (nurse staffing hours per patient day) and unit nurse characteristics (education and experience). Analyses were adjusted for patient characteristics, unit fixed effects, and clustering at the unit level.
Results
Continuous nurse assignment on the last 2 days of hospitalization was observed in 6,441 (35.4%) patient discharges and was associated with a 0.85 absolute percentage point reduction (7.8% relative reduction) in readmissions. There was no significant association with emergency department or observation visits. Sensitivity analysis revealed a stronger effect in patients with higher Elixhauser Comorbidity Indexes. Readiness for discharge was not a mediator of the effect of continuity on return to hospital. Unit characteristics were not associated with nurse continuity. No moderation effect was evident for unit environment and nurse characteristics.
Discussion
Continuity of nurse assignment on the last 2 days of hospitalization can reduce readmissions. Staffing for continuity may benefit patients and healthcare systems, with greater benefits for high-comorbidity patients. Nurse continuity prior to hospital discharge should be a priority consideration in assigning acute care nurses to augment readmission reduction efforts.
This integrative review analyzes research on the relationship of Home Health Care (HHC) to readmissions, specifically, identifying moderating and mediating factors and measurement constraints influencing effectiveness evaluations of HHC in reducing readmissions. HHC patients' readmission rates are higher than patients not receiving home health services but measurement of effectiveness is confounded by both practice variation and comparisons using noncomparable control groups. Effectiveness evaluations of HHC in reducing readmission requires attention to sample comparability and control for mediating variables. Establishing evidence of effectiveness clarifies the utility of HHC as a strategy to reduce readmissions.
Aim
To describe clinical nurses' experiences with practice change associated with participation in a multi‐site nursing translational research study implementing new protocols for hospital discharge readiness assessment.
Background
Nurses' participation in translational research studies provides an opportunity to evaluate how implementation of new nursing interventions affects care processes within a local context. These insights can provide information that leads to successful adoption and sustainability of the intervention.
Methods
Semi‐structured focus groups from 30 of 33 participating study hospitals lead by team nurse researchers.
Results
Nurses reported improved and earlier awareness of patients' discharge needs, changes in discharge practices, greater patient/family involvement in discharge, synergy and enhanced discharge processes, and implementation challenges. Participating nurses related the benefits of participation in nursing research.
Conclusion
Participation in a unit‐level translational research project was a successful strategy for engaging nurses in practice change to improve hospital discharge.
Implications for Nursing Management
Leading unit‐based implementation of a structured discharge readiness assessment including nurse assessment and patient self‐assessment encourages earlier awareness of patients' discharge needs, improved patient assessment and greater patient/family involvement in discharge preparation. Integrating discharge readiness assessments into existing discharge care promotes communication between health team members that facilitates a timely, coordinated discharge.
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