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.
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