The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial

Abstract

Aims Rate and number of successful cases in open heart surgery has been increasing due to the advances in medical technology and surgery. To improve patient convalescence results and reduce rate of post-discharge readmission to hospital and unplanned post-discharge rehospitalization, home-care and follow-up process of patients should be managed successfully. To evaluate the effectiveness of Nurse Led Transitional Care Model on the functional autonomy, quality of life, readmission, and rehospitalization rates of elderly patients undergoing open heart surgery. A randomized controlled trial was conducted from November 2017 to December 2018 and performed according to the CONSORT Guidelines. Methods and results Sixty-six elderly patients were randomly allocated to the intervention (n: 33) and control (n: 33) groups. Patients in intervention group were given care based on the Transitional Care Model until the post-discharge 9th week starting from date of hospitalization. Patients in control group were given standard care services. Functional autonomy, quality of life levels, and repeated admission/re-hospitalization rates to the clinic were evaluated. The Functional Autonomy Measurement System and SF-36 Quality of Life Scale scores of the intervention group were higher than that of the control group at the 9th week (P < 0.05). In addition, rate of readmission and rehospitalization during the follow-up period (6 months) of patients in the intervention group was found to be lower than the patients in the control group (P < 0.05). Conclusion Care services offered under the Transitional Care Model improved functional autonomy and quality of life and decreased post-discharge hospital readmission and rehospitalization rates of patients. Trial registration The study was registered on ClinicalTrials.gov (ID: NCT04384289).

Questionnaire Survey-Based Quantitative Assessment of the Impact of Transitional Care on Self-Management of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

“…Likewise, a randomized controlled trial assessed nurse-led TC for old people with open heart surgery. It was suggested that patient's life quality and functional autonomy are markedly increased, while rehospitalization and hospital readmission rates after discharge are conspicuously decreased [ 22 ]. TC also improves acute attack patient's life quality [ 23 ].…”

Impact of NP follow-up calls on reducing 30-day readmissions in patients with stroke

“…20 Additional studies revealed successful outcomes of 7-to 10-day postdischarge phone calls. 18,20,22 Given the signifi cance of 30-day readmissions in relation to increased mortality and healthcare costs and decreased quality of life of individual patients and families, implementing postdischarge telephone followup calls within 7-10 days of discharge is essential.…”

“…A cohort study emphasized the importance of timely follow-up calls to reduce 30-day readmission rates; the critical window for readmission is the first 2-3 weeks after discharge, with a median time of readmission at 11 days 20. Additional studies revealed successful outcomes of 7- to 10-day postdischarge phone calls 18,20,22. Given the significance of 30-day readmissions in relation to increased mortality and healthcare costs and decreased quality of life of individual patients and families, implementing postdischarge telephone follow-up calls within 7-10 days of discharge is essential.…”

“…16,17 Specifi cally, postdischarge telephone follow-up by nurses, trained coaches, interns, and NPs have shown positive outcomes for reducing readmission rates in patients with stroke. [18][19][20][21][22] A cohort study emphasized the importance of timely follow-up calls to reduce 30-day readmission rates; the critical window for readmission is the fi rst 2-3 weeks after discharge, with a median time of readmission at 11 days. 20 Additional studies revealed successful outcomes of 7-to 10-day postdischarge phone calls.…”

“…To reduce readmission rates, current literature supports a variety of successful pre- and postdischarge interventions including discharge planning, patient education, follow-up telephone calls, home visits, and transition coaching 16,17. Specifically, postdischarge telephone follow-up by nurses, trained coaches, interns, and NPs have shown positive outcomes for reducing readmission rates in patients with stroke 18-22. A cohort study emphasized the importance of timely follow-up calls to reduce 30-day readmission rates; the critical window for readmission is the first 2-3 weeks after discharge, with a median time of readmission at 11 days 20.…”