The current research proposal is aimed at investigating the impact of improving the transition procedures following a discharge of a patient from a hospital on the rates of hospital readmissions. Therefore, the purpose of the proposed EBP project is to investigate the impact of an intervention for gathering additional information from the hospital by a home health nurse (I), when compared to the standard transition procedures (C), on the rates of hospital readmission (O) within three months after the initial hospital discharge (T) among patients with chronic obstructive pulmonary disease (COPD) or heart failure who were discharged from a hospital after treating these conditions there (P).
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It is paramount to discuss the background of the problem of transition of patients after they were discharged from a hospital. Overall, it is stated that the process of transition after discharge from a hospital is poorly organized in a prevalent number of cases; in particular, this pertains to the process of transition of patients with COPD (Ospina et al., 2018). It is also stressed that patients with heart failure often experience rehospitalization after they have been discharged from a hospital (Donaho et al., 2015). Estrella-Holder, Schaffer, Malik, & Zieroth (2016) point out that heart failure is the leading reason for hospital readmissions, and that the transition period is of risk to patients.
Besides, Doos et al. (2014) aver that patients with several comorbid health conditions, such as those suffering from heart failure and COPD at the same time, are often subjected to a multitude of challenges during their hospital transition, and that they often experience problems when it comes to communication with or among medics. It is stated that there often exist problems with the transfer of information about medication regimes and to the patient diagnosis, as well as with continuity of care following the process of transition (Doos et al., 2014). Also, Ospina et al. (2018) proposed that a discharge bundle for patients with severe exacerbations of COPD may be a viable and effective tool for improving patient transition. Therefore, it is possible to conclude that patients with COPD and heart failure are under risk during their transition from the hospital setting, that they often experience hospital readmissions within a few months after discharge, and that the process of transition is often organized in a suboptimal manner.
The problem of investigating interventions aimed at improving patient transition after the discharge from a hospital for individuals suffering from COPD and heart failure is of great clinical significance. This is because of the said high frequency of hospital readmissions among these patients and because of the considerable risks that they are known to face, as well as the fact that research shows that such interventions may provide considerable improvements when it comes to readmission rates. For example, Estrella-Holder et al. (2016) found out that a clinic providing the service of nurse practitioner managed transitions was successful in lowering the rates of hospital readmissions among patients with heart failure. Similarly, Donaho et al. (2015) discovered that transition care provided for patients with heart failure after their discharge from a hospital was associated with a profound decrease in the rates of hospital readmission for these individuals. This means that the proposed project is of considerable clinical significance because it may help reduce the readmission rates and assist with improving health outcomes for patients with COPD and heart failure who were discharged from hospitals.
For the proposed study, it is possible to utilize such a theoretical framework as the Ideal Transition of Care (ITC), as described by Burke, Guo, Prochazka, and Misky (2014). This theoretical framework provides a model that allows for classifying interventions provided for patients who have been discharged from the hospital to be able to more effectively analyze the contents of these interventions and find out what areas are covered when a particular intervention is carried out on a certain patient. According to ITC, there exist 10 main domains in which an improvement could be made to potentially lower the rates of hospital readmissions:
- “Complete communication of information” (CCI) – pertains to the information that is provided for the medic who receives the patient (Burke et al., 2014, p. 6);
- “Availability, timeliness, clarity, and organization of information” (AT) – reflects the fact that the information is provided for the receiving medic, and records the time of this provision (Burke et al., 2014, p. 6);
- “Medication safety” (MS) – describes the degree to which drugs are reconciled with one another during the whole period during which the patient receives medical care (Burke et al., 2014, p. 6);
- “Educating patients to promote self-management” (EP) – pertains to the provision of patient education, as well as caregiver education, based on such principles as teach-back and health literacy (Burke et al., 2014, p. 6);
- “Monitoring and managing symptoms after discharge” (MM) – involves various interventions with the use of innovative technologies (phone calls, telehealth), as well as availability of a medic who could respond to the patient’s concerns (Burke et al., 2014, p. 6);
- “Enlisting help of social and community supports” (EH) – relates to evaluating the home environment according to its ability to provide support and assistance if these are required (Burke et al., 2014, p. 6);
- “Advanced care planning” (AC) – is associated with creating a health care proxy and with defining the aims of the provision of care (Burke et al., 2014, p. 6);
- “Coordinating care among team members” (CCA) – reflects that degree to which medical records are shared between health care providers, the existence and quality of communication between members of the medical team, and the continuity of health care suppliers (Burke et al., 2014, p. 6);
- “Discharge planning” (DP) – stresses upon the importance of identifying the needs of the patient before discharging them, as well as providing interventions before the process of discharge takes place (Burke et al., 2014, p. 6);
- “Follow-up with outpatient providers” (FO) – assesses the presence of appropriate follow-up with the correct health care specialists during a proper timeframe (Burke et al., 2014, p. 6).
According to Burke et al. (2014), most interventions that currently exist and are utilized to improve patient transitions are aimed at nearly 3.5 domains (out of the 10 domains that were named above) on the average. Therefore, it is suggested that proposing interventions that would attempt to enhance transition in a larger number of domains could be more effective (Burke et al., 2014). Thus, the said theoretical framework might be of considerable assistance when developing and implementing interventions aimed at enhancing patient transition rates to reduce hospital readmissions.
Review of Literature
Generally speaking, it should be stressed that according to the literature, heart failure is the leading cause of readmissions to the hospital. Estrella-Holder et al. (2016) observe that nearly 16% of the patients with heart failure are readmitted to the researcher’s hospital (in Canada) and that this finding is consistent with the data gained not only nationwide in Canada but also internationally. Similarly, COPD is also a cause of rather frequent hospital readmissions (Sharif, Parekh, Pierson, Kuo, & Sharma, 2014). Sharif et al. (2014) emphasize that in a large U.S. sample of individuals who had COPD and used a large private plan for health insurance (N = 8,263 of patients who satisfied the criteria for inclusion), 8.9% of these patients (N = 741) experienced readmission to hospital within 30 days from their discharge (p. 690). This means that it is paramount to better study the main reasons for readmission of such patients and take steps aimed at lowering the rates of readmission to prevent exacerbation of heart failure, COPD, or possible comorbid conditions in the population.
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Multiple studies investigate the reasons for early hospital readmissions, as well as the factors that are associated with such readmissions among patients with the said diseases. For example, the study by Sharif et al. (2014) has shown that there exists a multitude of factors that are significantly correlated with early readmission of patients initially hospitalized with COPD. More specifically, these include factors about a particular patient (male sex; the presence of comorbid diagnoses of lung cancer, depression, or osteoporosis; having a previous history of heart failure), to the health care provider (the absence of the previous prescription of statin 12 mo before index admission; the absence of prescription of short-acting bronchodilators, antibiotics, or oral steroids within 30 days of discharge), and, finally, to factors related to the system of health care (length of stay at the hospital that is shorter than two days or longer than five days; the absence of follow-up visits to the health care provider after the patient was discharged from the hospital; Sharif et al., pp. 691-692).
Also, Nguyen et al. (2014) discovered that moderate or vigorous physical activity is statistically significantly (p <.05) correlated with lower readmission risks for COPD patients discharged from hospitals (for patients performing 1-149 minutes of such activity per week, the relative risk was.67, and for patients performing more than 150 minutes of such activity per week, the relative risk was.66). It is also stated that such factors as anemia, long stay in the hospital, the history of prior hospitalizations, additional comorbid conditions, the utilization of emergency department, the receipt to for a new prescription of oxygen during the process of discharge, and observational stay before readmission were all statistically significantly (p <.05) associated with increased readmission rates (Nguyen et al., 2014, pp. 701-702). Interestingly, the absence of a partner was marginally significant (p =.08) associated with greater readmission rates (Nguyen et al., 2014, pp. 701-702).
On the whole, various interventions aimed at providing better care during the transition and after it are correlated to lower rates of hospital readmissions in a multitude of research studies (Coughlin, Liang, & Parthasarathy, 2015; Estrella-Holder et al., 2016; Donaho et al., 2015; Milfred-LaForest et al., 2017; Ospina et al., 2018). For instance, according to Coughlin et al. (2015), medication reconciliation carried out by a pharmacist, combined with advanced positive airway pressure (or noninvasive positive pressure ventilation) administered nocturnally by a specialist in respiratory therapy (who also supplies ongoing care), along with sufficient provision with oxygen and patient education, was associated with considerably decreased hospital readmission rates for patients with COPD. Also, Milfred-LaForest et al. (2017) argue that such elements of transition as the reconciliation of medications care provided by specialists of different medical disciplines, early follow-up after the discharge from the hospital, as well as rapid intervention in the case when symptoms or signs of heart failure emerge, might allow for decreasing the rates of readmission within 30 days of discharge from a hospital for patients with heart failure.
Similarly, according to Donaho et al. (2015), providing transition care for patients with congestive heart failure in a post-discharge transition clinic using a protocol allows for lowering the readmission rates to the hospital by a considerable percentage. Also, Estrella-Holder et al. (2016), after their pilot study, also reported that a clinic providing transition managed by a nurse practitioner, which included the utilization of guidelines-based therapy, the assessment of ejection fraction, the provision of patient education about self-care, and health management, as well as supplying the patient with cardiac rehabilitation referrals, was associated with a decrease in readmission rates of patients with heart failure when compared to historical rates of readmissions.
It should also be observed that hospitals may be more inclined to take steps aimed at decreasing the rates of patient readmissions after their discharge because of the legal policies that might be put in place. For instance, according to Feemster & Au (2014), some legal initiatives may penalize hospitals that have extremely high rates of readmission of patients with COPD using an array of methods. This makes hospitals more interested in providing high-quality transition care for their patients with COPD to reduce their readmission rates and avoid being penalized if the latter is too high.
Therefore, the research literature indicates that provision of additional transitional care when a patient with heart failure or COPD is discharged from a hospital may be capable of considerably reducing the rates of readmissions of these patients within 30 days after the said discharge (Coughlin et al., 2015; Donaho et al., 2015; Ospina et al., 2018). At the same time, it is difficult to select the best way of providing a transition for those patients who are simultaneously suffering from two comorbid conditions, namely, COPD and heart failure. Therefore, it is paramount to develop a transition method that would allow for combining the elements of transition practices that are effective for patients who suffer from only one of the said disorders while simultaneously reviewing them to reconcile the different medication regimens prescribed for patients and avoid administering any drugs or procedures that would be capable of producing unwanted side effects in combination. It is also pivotal to ensure that the proposed intervention would be capable of addressing a sufficient number of domains as described by the ITC theoretical framework (Burke et al., 2014) to achieve more exhaustive care for the patient, more effectually reduce the rates of complications, and improve patient outcomes, consequently lowering the readmission rates within 30 days since the patient’s discharge from their hospital.
Burke, R. E., Guo, R., Prochazka, A. V., & Misky, G. J. (2014). Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Services Research, 14(1), 423. Web.
Coughlin, S., Liang, W. E., & Parthasarathy, S. (2015). Retrospective assessment of home ventilation to reduce rehospitalization in chronic obstructive pulmonary disease. Journal of Clinical Sleep Medicine: Official Publication of the American Academy of Sleep Medicine, 11(6), 663-670.
Donaho, E. K., Hall, A. C., Gass, J. A., Elayda, M. A., Lee, V. V., Paire, S., & Meyers, D. E. (2015). Protocol‐driven allied health post‐discharge transition clinic to reduce hospital readmissions in heart failure. Journal of the American Heart Association, 4(12), e002296.
Doos, L., Bradley, E., Rushton, C. A., Satchithananda, D., Davies, S. J., & Kadam, U. T. (2014). Heart failure and chronic obstructive pulmonary disease multimorbidity at hospital discharge transition: A study of patient and carer experience. Health Expectations, 18(6), 2401-2412.
Estrella-Holder, E., Schaffer, S. A., Malik, A., & Zieroth, S. (2016). Improving access to heart failure care: Pilot study of a nurse practioner managed-post hospital discharge transition clinic. Canadian Journal of Cardiology, 32(10), s140.
Feemster, L. C., & Au, D. H. (2014). Penalizing hospitals for chronic obstructive pulmonary disease readmissions. American Journal of Respiratory and Critical Care Medicine, 189(6), 634-639.
Milfred-LaForest, S. K., Gee, J. A., Pugacz, A. M., Piña, I. L., Hoover, D. M., Wenzell, R. C.,… Ortiz, J. (2017). Heart failure transitions of care: A pharmacist-led post-discharge pilot experience. Progress in Cardiovascular Diseases, 60(2), 249-258.
Nguyen, H. Q., Chu, L., Liu, I. L. A., Lee, J. S., Suh, D., Korotzer, B.,… Gould, M. K. (2014). Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease. Annals of the American Thoracic Society, 11(5), 695-705.
Ospina, M. B., Michas, M., Deuchar, L., Leigh, R., Bhutani, M., Rowe, B. H.,… Stickland, M. K. (2018). Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease. BMJ Open Respiratory Research, 5(1), e000265.
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Sharif, R., Parekh, T. M., Pierson, K. S., Kuo, Y. F., & Sharma, G. (2014). Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Annals of the American Thoracic Society, 11(5), 685-694.