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McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care. Based on the success of this test, Patient Safe-D was incorporated as part of the Society of Hospital Medicine's Project BOOST (Better Outcomes for Older Adults through Safe Transitions) initiative which uses medication reconciliation, teach back and the Discharge Patient Education Tool (DPET) to help reduce medication-related errors. BOOST provides a full implementation toolkit to help institutions implement this and other programs to improve discharge education.

Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35(10):1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.  

A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits, hospital admissions, readmissions, and total bed days; and generated high levels of physician and patient satisfaction. These successes have been across a variety of health system contexts, including: a VA medical center, primary care health centers, and as a part of a Medicare Advantage plan. A recent analysis found that the reduction in service usage saved the VA medical center $200k per year for the 179 veterans enrolled in GRACE. Another analysis in primary care health centers found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year 3.

The program was initially designed to serve low-income seniors, but has subsequently been replicated with different populations, including adults of all ages who are high risk, Medicare beneficiaries who are 70+ with multiple comorbidities, and older veterans following an emergent hospital admission and discharge home.

Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Lacker C. Am J Nurs. 2011;111(11):65-69.
Analyzing data from the Pennsylvania Patient Safety Authority Reporting System, this commentary identifies contributing factors to readmissions and suggests tactics to prevent them.