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Oncology Patients’ Hospital Readmission Prevention


The project is focused on finding pre-discharge and post-discharge techniques that can help reduce hospital readmissions of adult oncology patients. One of the best potential solutions belongs to Merkow et al. (2015), who suggest that the major evidence-based way to decrease the readmission rate is scheduling follow-up visits for patients who are likely to have postoperative complications. According to Merkow et al. (2015), planned hospital visits have a high potential of reducing the possibility of hospitalization for the patients. Moreover, pre-discharge education for adult oncology patients improves the outcomes of surgery. Therefore, there are two effective solutions to reducing hospital readmission rates for post-operative adult oncology patients: follow-up visits and pre-discharge education. With the help of these approaches, patients will obtain an opportunity to remain aware of their condition and maintain the kind of lifestyle that promotes their health.

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Change Model Overview

The change model that will be employed in the project is the ACE Star model (“The ACE Star model,” n.d.). With the help of this model’s five key elements, it is possible to arrange a better understanding of the characteristic features of the information and knowledge employed in different facets of evidence-based practice (EBP). The ACE Star model helps nursing professionals to situate their previous scholarly endeavors within the EBP context, instructs how to apply EBP, and establishes the place of nursing within the EBP network (“The ACE Star model,” n.d.). Not only does this model incorporate the common data, but it also singles out the unique features of EBP. The following five stages of knowledge transformation are represented in the model:

  1. “discovery research;”
  2. “evidence summary;”
  3. “translation to guidelines;”
  4. “practice integration;”
  5. “process, outcome evaluation” (“The ACE Star model,” n.d.).

The model should be used as a guide to promote change because it contains a detailed division and explanation of the knowledge transformation process.

Define the Scope of the EBP

The practice issue is the prevention of hospital readmission rates for adult oncology patients after surgery. The statistics indicate that in 2012, the unplanned readmission rate in the US was 5.7% for 498 875 operations (Merkow et al., 2015). What concerns individual procedures, the readmission rate varied between 3.8% (hysterectomy) and 14.9% (lower extremity vascular bypass) (Merkow et al., 2015). The predominant cause of unplanned readmission was surgical site infection overall (19.5%) (Merkow et al., 2015). As little as 2.3% of patients’ readmission complications were the same as in the course of index hospitalization (Merkow et al., 2015). This problem has a great impact on the healthcare system since additional hospital admissions require more financial and human resources on the part of hospitals as well as cause additional inconveniences for the patients (Mays, Worley, Ackall, D’Agostino, & Waltonen, 2015). Therefore, post-surgical readmissions present a challenge to the healthcare system that should be managed in order to increase patient outcomes and arrange better conditions for healthcare employees.


Apart from the leader of the team, the project will engage several other stakeholders. Together with the leader, the team will consist of seven members:

  • an oncologist;
  • a psychologist;
  • a pharmacist;
  • charge nurse;
  • two nurses.

Determine Responsibility of Team Members

Each member of the team will have different duties, but they will need to combine their efforts and share their experience to reach the desired outcomes. The major responsibility of the oncologist will be preparing a pre-discharge education plan for patients. The psychologist will help patients to accommodate to their post-operative condition and encourage them to do their best in the way of improving their health. The pharmacist’s duty will be assisting the oncologist in choosing the most appropriate post-operative treatment. The charge nurse will control the process of coordinated work. The nurses will help each team member and look after the patients while they are still at the hospital.


The problem of hospital readmission of adult oncology patients who have undergone surgery is discussed in many research papers. Mays et al. (2015) analyze the post-surgical complications of patients with head and neck cancer. Merkow et al. (2015) dedicate their research to the analysis of major causes of readmissions and suggest possible ways of decreasing readmission rates. Hall, Chang, and O’Grady (2016) also dedicate their study to the ways of reducing the rates of readmissions and improving patient outcomes. Waller et al. (2015) discuss the options of pre-operative education for oncology patients. The strength of the current project is that it suggests two approaches to coping with the problem, which increases the possibility of success. Also, the activity of a team of professionals is more likely to manage the issues that one person’s efforts.

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Summarize the Evidence

The systematic review article by Hall et al. (2016) does not focus on adult oncology patients, but it emphasizes the need to reduce the number of readmission cases. The authors suggest activities that might be employed by caseworkers in the way of improving patient outcomes. The evidence-based interventions mentioned in the article are the improvement of patient-provider communication, the arrangement of a coordinated plan of actions combining hospital and home care, and the enhancement of patients’ health education. Another research that might be useful in the project is the one performed by Waller et al. (2015). The authors remark that pre-operative education provided for the patients minimizes the risk of complications and postoperative readmissions.

Develop Recommendations for Change Based on Evidence

Grounded on the evidence from research, the recommended solutions are:

  1. to arrange pre-discharge education for the patients who have undergone surgery;
  2. to schedule post-operative follow-up patient visits to the hospital.

The aim of these recommendations is to reach the reduction of readmission rates.


Action Plan

  1. preparation of educational materials for pre-discharge education;
  2. creating the schedule for follow-up visits;
  3. introducing the knowledge base to the patients;
  4. gathering evidence;
  5. evaluating outcomes: comparing the readmission rates during the project and over a chosen period of the past activity.

The timeline of the project:

  1. preparing the knowledge base: 3 weeks;
  2. introducing the educational materials: 4 weeks;
  3. preparing and presenting a follow-up plan: different for every patient, 1-2 days to 1-2 weeks;
  4. analysis: 2 weeks;
  5. preparing the report: 3 weeks.

Process, Outcomes Evaluation, and Reporting

The outcomes will be measured by comparing readmission rates at different periods. The expected result is the decrease in readmission rates. Stakeholders will be informed about the results through a report.

Identify Next Steps

The next steps will be inviting other hospital departments and other hospitals to use the EBP of the project to minimize the readmission rates. To ensure the permanence of the implementation, it will be necessary to perform regular control over the process.

Disseminate Findings

The findings will be shared internally and externally through a report prepared by the project leader.

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The project is focused on decreasing the readmission rate among adult oncology patients who have undergone surgery. The intervention incorporates two major steps: pre-discharge education and scheduled post-discharge visits. The ACE Star change model was rather helpful in creating the project. Its elements such as “evidence summary,” “discovery research,” and “process, outcome evaluation” were used to complete the plan (“The ACE Star model,” n.d.). The process of maintaining the plan will be supported through control over the team members’ adherence to their duties and patients’ desire to collaborate.


The ACE Star model. (n.d.). Web.

Hall, K. K., Chang, A. B., & O’Grady, K. F. (2016). Discharge plans to prevent hospital readmission for acute exasperations in children with chronic respiratory illness (Protocol). Cochrane Database of Systematic Reviews, 8, 1-9.

Mays, A. C., Worley, M., Ackall, F., D’Agostino, R., & Waltonen, J. D. (2015). The association between gastrostomy tube placement, poor post-operative outcomes, and hospital re-admissions in head and neck cancer patients. Surgical Oncology, 24(3), 248-257.

Merkow, R. P., Ju, M. H., Chung, J. W., Hall, B. L., Cohen, M. E., Williams, M. V.,… Bilimoria, K. Y. (2015). Underlying reasons associated with hospital readmission following surgery in the United States. JAMA, 313(5), 483-495.

Waller, A., Forshaw, K., Bryant, J., Carey, M., Boyes, A., & Sanson-Fisher, R. (2015). Preparatory education for cancer patients undergoing surgery: A systematic review of volume and quality of research output over time. Patient Education and Counseling, 98(12), 1540-1549.

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