The Transition Procedures Following a Patient Discharge

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, 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. On the whole, 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 has been found to be the leading reason for hospital readmissions, and that the transition period is of particular risk to patients.

In addition, 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. In particular, it is stated that there often exist problems with transfer of information pertaining to 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, on the whole, 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 or 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 due to 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) discovered 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 or heart failure who were discharged from hospitals.


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.

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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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StudyCorgi. (2020) 'The Transition Procedures Following a Patient Discharge'. 5 December.

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