Kathleen Bobay

Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization

OBJECTIVES To determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing. DATA SOURCES Patient questionnaires, electronic medical records, and administrative data for 1,892 medical-surgical patients from 16 nursing units within four acute care hospitals between January and July 2008. DESIGN Nested panel data with hospital and unit-level fixed effects and patient and unit-level control variables. DATA COLLECTION/EXTRACTION Registered nurse (RN) staffing was recorded monthly in hours-per-patient-day. Patient questionnaires were completed before discharge. Thirty-day readmission and ED use with reimbursement data were obtained by cross-hospital electronic searches. PRINCIPAL FINDINGS Higher RN nonovertime staffing decreased odds of readmission (OR=0.56); higher RN overtime staffing increased odds of ED visit (OR=1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.

Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization.

11.64 million and U.S.

Age-Related Differences in Perception of Quality of Discharge Teaching and Readiness for Hospital Discharge

544,000 annually for the 16 study units. CONCLUSIONS Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge.

Validation of Patient and Nurse Short Forms of the Readiness for Hospital Discharge Scale and Their Relationship to Return to the Hospital

Background:Prevention of hospital readmission and emergency department (ED) utilization will be a crucial strategy in reducing health care costs. There has been limited research on nurse assessment and patient perceptions of discharge readiness in relation to postdischarge outcomes. Objectives:To investigate the association of nurse and patient assessments of discharge readiness with postdischarge readmissions and ED visits. Research Design:Hierarchical regression analysis of readmission or ED utilization using independent nurse and patient assessments of discharge readiness and patient characteristics as explanatory variables, with hospital and unit fixed effects. Subjects:A total of 162 adult medical-surgical patients and their discharging nurses from 13 medical-surgical units of 4 Midwestern hospitals. Measures:Readiness for Hospital Discharge Scale completed independently by patients and their discharging nurses within 4 hours before hospital discharge; Postdischarge utilization (unplanned readmission or ED visit within 30 days postdischarge). Results:Correlations between nurse assessment and patient perceptions of discharge readiness were low (r = 0.15–0.32). Nurses rated patient readiness higher than patients themselves. Controlling for patient characteristics, nurse readiness for hospital discharge scale score (odds ratio = 0.57, P = 0.05) but not patient readiness for hospital discharge scale score was associated with postdischarge utilization. Conclusions:Nurse assessment was more strongly associated with postdischarge utilization than patient self-assessment. Formalizing nurse assessment of discharge readiness could facilitate identification of patients at risk for readmission or ED utilization before discharge when anticipatory interventions could prevent avoidable postdischarge utilization.

The relationship of nurses' professional characteristics to levels of clinical nursing expertise

Adults aged 65 and older account for one third of all hospitalizations in the United States.(1) Almost one fifth (19.6%) of Medicare beneficiaries discharged from an acute care hospital are readmitted within 30 days.(2) High readmission rates have been attributed to inadequate discharge preparation, lack of patient and family caregiver readiness, poor discharge transition coordination, and unsuccessful coping with the demands of daily living.(3-9) Discharge needs may be different for older adults than for the general population because of the increased likelihood of multiple comorbidities, illness-induced limitations, impaired mobility, fatigue, anxiety, cognitive impairment, hearing impairments, health literacy deficits, and living alone.(7,8,10-12) The purpose of this study was to investigate differences in perceptions of the quality of discharge teaching and readiness for hospital discharge and their relationship to postdischarge utilization of emergency department (ED) visits and readmissions across the older adult age spectrum. Of particular interest is the applicability of quality of discharge teaching and discharge readiness assessment tools for the older adult population.

Methodology issues in implementation science.

OBJECTIVE To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits. DATA SOURCES/STUDY SETTING A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. STUDY DESIGN Prospective longitudinal design, multinomial logistic regression analysis. DATA COLLECTION/EXTRACTION METHODS Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. PRINCIPAL FINDINGS Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits. CONCLUSIONS Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk.

Failure to rescue: a preliminary study of patient-level factors.

Many hospitals are searching for guidelines for professional practice models, which are a requirement for Magnet recognition. This study was undertaken to determine the professional nursing characteristics that may contribute to the development of clinical nursing expertise. Experience as an RN was found to be highly correlated with initial level of expertise. Educational preparation and certification were not correlated with expertise. This research suggests that nurses may require more on-the-job experience for the development of clinical nursing expertise than what has been reported in the literature.

Identification of Patients at Risk for Falls in an Inpatient Rehabilitation Program.

Background:Putting evidence into practice at the point of care delivery requires an understanding of implementation strategies that work, in what context and how. Objective:To identify methodological issues in implementation science using 4 studies as cases and make recommendations for further methods development. Research Design:Four cases are presented and methodological issues identified. For each issue raised, evidence on the state of the science is described. Results:Issues in implementation science identified include diverse conceptual frameworks, potential weaknesses in pragmatic study designs, and the paucity of standard concepts and measurement. Conclusions:Recommendations to advance methods in implementation include developing a core set of implementation concepts and metrics, generating standards for implementation methods including pragmatic trials, mixed methods designs, complex interventions and measurement, and endorsing reporting standards for implementation studies.

Comparison of nurse staffing based on changes in unit-level workload associated with patient churn

This study explored patient-level factors associated with failure to rescue (FTR). The overall incidence of FTR in 5 Midwestern hospitals was 0.03%, which is much lower than reported in other studies. Five key patient parameters were found to be statistically significant, but subtle, indicators of impending FTR. These were changes in heart rate, respiratory rate, temperature, serum sodium levels, and urine output. Use of patient-level data allows for more accurate reporting of actual FTR events.

Effectiveness of Multimodal Pain Management Protocol in Total Knee Arthroplasty Patients

Purpose: To determine if there is a more sensitive method to identify inpatient rehabilitation patients at high risk for falls rather than the Morse fall scale. Method: Retrospective analysis of falls occurring during 6‐month period in 2009. Age and diagnosis were used to create comparison groups between patients who fell and those who did not. T‐tests were used to determine differences between the two groups in FIM scores and Morse fall scores. Results: Patients who had stroke as a primary diagnosis were more likely to fall than other patients. Length of stay was greater for patients who fell (p = .008). The positive predictive value of the Morse fall scale for patients who fell was 57%, suggesting that it is not a sensitive predictor of falls in rehabilitation patients. Patients who fell had significantly lower FIM expression scores (p = .02).