Nancy L. Novotny

Prediction of early readmission in medical inpatients using the Probability of Repeated Admission instrument.

Background: In the absence of an instrument to predict risk of early readmission, examination of the well-validated probability of repeated admission (Pra) for this new purpose is indicated. Objective: The objective of this study was to examine the use of the Pra in accurately identifying and predicting adult medical inpatients at risk of early readmission. Methods: Over 20 months, 1,077 consecutively admitted medical patients were enrolled in this prospective cohort study at a Midwestern tertiary care medical center. Pra score values were calculated within 2 days of discharge. Databases at the index medical center and other institutions were queried to identify readmission within 41 days. Results: Prevalence of readmission was 14% (confidence interval = 12.4%-15.6%). Pra score values ranged from .16 to .75. Indices to identify and predict readmission for a range of cut points were reported to minimize loss of information. The likelihood ratio for patients with a Pra score value ≥.53 was 1.67. Using a Pra cut point of ≥.45, readmission of patients with a high Pra was 2.3 times more likely than that of patients with a low Pra (p < .001, confidence interval = 1.63-3.27). Comparisons between cohorts indicated that differences existed with four of the eight variables used to calculate the Pra score: diabetes (p = .01), self-rated health status (p = .007), and number of doctor visits (p < .001) and hospitalizations (p < .001) in the past year. Discussion: Within this heterogeneous sample, prediction of readmission using the Pra was better than chance. These findings may facilitate development of a better predictive model by combining select Pra variables with other variables associated with early readmission.

Patient and physician perceptions after software‐assisted hospital discharge: Cluster randomized trial

BACKGROUND Hospital discharge software potentially improves communication and clinical outcomes. OBJECTIVE To measure patient and physician perceptions after discharge with computerized physician order entry (CPOE) software. DESIGN Cluster randomized controlled trial. SETTING Tertiary care, teaching hospital in central Illinois. PATIENTS A total of 631 inpatients discharged to home with high risk for readmission. INTERVENTION A total of 70 internal medicine hospital physicians randomly assigned (allocation concealed) to discharge software vs. usual care, handwritten discharge. MEASUREMENTS Discharge perceptions from patients, outpatient primary care physicians, and hospital physicians. RESULTS One week after discharge, 92.4% (583/631) of patients answered interviews. For 78.6% (496/631) of patients, their outpatient physicians returned questionnaires 19 days (median) postdischarge. Generalized estimating equations gave intervention variable coefficients with 95% confidence intervals (CIs). When comparing patients assigned to discharge software vs. usual care, patient mean (standard deviation [SD]) scores for discharge preparedness were higher (17.7 [4.1] vs. 17.2 [4.0]; coefficient = 0.147; 95% CI = 0.005-0.289; P = 0.042), patient scores for satisfaction with medication information were unchanged (12.3 [4.8] vs. 12.1 [4.6]; coefficient = -0.212; 95% CI = -0.937-0.513; P = 0.567), and their outpatient physicians scored higher quality discharge (17.2 [3.8] vs. 16.5 [3.9]; coefficient = 0.133; 95% CI = 0.015-0.251; P = 0.027). Hospital physicians found mean effort to use discharge software was more difficult than the usual care (6.5 [1.9] vs. 7.9 [2.1]; P = 0.011). CONCLUSIONS Discharge software with CPOE caused small improvements in discharge perceptions by patients and their outpatient physicians. These small improvements might balance the difficulty perceived by hospital physicians who used discharge software.

Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial.

BACKGROUND One of the causes of postdischarge adverse events is poor discharge communication between hospital-based physicians, patients, and outpatient physicians. The value of hospital discharge software to improve communication and clinically relevant outcomes is unknown. OBJECTIVE To measure effects of a discharge software application of computerized physician order entry (CPOE). DESIGN Cluster randomized controlled trial. SETTING Tertiary care, teaching hospital in central Illinois. PATIENTS A total of 631 inpatients discharged to home with high risk for readmission. INTERVENTION Seventy internal medicine hospital physicians were randomly assigned (allocation concealed) to discharge software versus usual care, handwritten discharge. MEASUREMENTS Blinded assessment of patient readmission, emergency department visit, and postdischarge adverse event. RESULTS A total of 590 (94%) patients provided 6-month follow-up data. Generalized estimating equations gave intervention variable coefficients with 95% confidence interval (CI). When comparing patients assigned to discharge software versus usual care, there was no difference in hospital readmission within 6 months (37.0% versus 37.8%; coefficient -0.005 [95% CI, -0.074 to 0.065]; P = 0.894), emergency department visit within 6 months (35.4% versus 40.6%; coefficient -0.052 [95% CI, -0.115 to 0.011]; P = 0.108), or adverse event within 1 month (7.3% versus 7.3%; coefficient 0.003 [95% CI; -0.037 to 0.043]; P = 0.884). CONCLUSIONS Discharge software with CPOE did not affect readmissions, emergency department visits, or adverse events after discharge. Future studies should assess other endpoints such as patient perceptions or physician perceptions to see if discharge software has value.

Exploring Reported Practice Habits of Registered Nurses and Licensed Practical Nurses at Illinois Nursing Homes

Introduction Nurses are expected to understand their states’ Nurse Practice Act (NPA) and practice within its scope. Role confusion can occur when nurses who practice with different scopes, such as registered nurses (RNs) and licensed practical nurses (LPNs), work closely together. Aim The purpose of this study is to examine the types of nursing activities performed by licensed nurses, and the extent to which RNs and LPNs in Illinois nursing homes are engaged in these activities. Methods A questionnaire was used to explore the types of nursing activities 140 nurses performed in 13 Illinois nursing homes and extent of their engagement in nursing activities within their scope of practice. Results Activities most frequently performed by all nurses included supervision of unlicensed assistive personnel, advocacy for residents, and collection of data to contribute to resident assessment. Both LPNs and RNs did not engage in the full extent of activities that their Illinois scope allowed, and LPNs completed activities that were not included in their scope. Conclusion Poor understanding exists about the differences between RN and LPN scope. Confusion about licensed nurses’ scopes of practice suggests that education about NPAs is needed. RNs indicated that they practice beyond their scope; however, it is not known in what way they practice beyond their scope.

Covariates predict medication discrepancies after therapeutic substitution (TS)

Clinical Pharmacology & Therapeutics (2003) 73, P75–P75; doi: