The effects of a transitional discharge model for psychiatric patients

This pilot randomized control trial was motivated by the discovery that many individuals with mental health problems are re-hospitalized within a year, with many being unable to fully adjust to community living. A solution was proposed in the form of an intervention called transitional discharge. The transitional discharge model included: (1) peer support, which is assistance from former patients who provide friendship, understanding and encouragement; and (2) overlap of inpatient and community staff in which the inpatient staff continue to work with the discharged patient until a working relationship is established with a community care provider. The overall aim of this study was to test the discharge model designed to assist patients discharged from acute admission wards to adjust to community living. This aim was tested through a number of related hypotheses, which suggest that, 5 months following discharge from an acute admission ward of a psychiatric hospital, individuals participating in a transitional discharge model: (1) report fewer symptoms; (2) report better levels of functioning; (3) have better quality of life; (4) are less likely to have been re-admitted to hospital. The study used a randomized experimental design with two conditions: experimental and usual treatment. In general, both the control and the experimental group demonstrated significant improvements in symptom severity and functional ability after 5 months. Usual treatment subjects in the control group were more than twice as likely to be re-admitted to hospital. This study needs to be replicated in Scotland with a larger sample and with a modified variation of the intervention called the Transitional Care Intervention.     

系统化全程护理干预对食管癌患者术后生活质量的影响

目的 探讨系统化全程护理干预对食管癌患者术后生活质量的影响.方法 选择我院胸外科行食管癌手术患者106例,按随机化原则分为对照组52例和干预组54例.对照组采取常规的治疗和护理;干预组在常规的治疗和护理基础上,加强心理指导、完善健康宣教、加强营养指导、出院后随访等全程化护理干预的方法 .观察对比两组患者焦虑抑郁水平、生活质量评分有无差异性.结果 经统计学处理,结果 发现两组患者焦虑抑郁水平、生活质量评分均有显著性差异(P<0.01,P<0.05).结论 临床结果 表明,对食道癌患者手术后进行加强心理指导、完善健康宣教、加强营养指导、出院后随访等系统化全程护理干预的方法 ,从心理、社会、疾病等多个方面,进行多元化、预见性护理,可以减轻食道癌患者手术后的负性心理状态,从心理和生理两方面促进患者的康复,提高患者的生活质量,对患者的生命意义具有积极的促进作用.可取得较好的经济效益和社会效益,值得临床推广应用.     

Five-year survival, quality of life, and individual costs of 303 consecutive medical intensive care patients--a cost-utility analysis

OBJECTIVE: To assess long-term survival, health-related quality of life, and associated costs 5 yrs after discharge from a medical intensive care unit. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a German university hospital. PATIENTS: Three hundred and three consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between November 1997 and February 1998 with an intensive care unit length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and individual intensive care unit and hospital costs were prospectively recorded. Primary outcomes included 5-yr survival, functional status, health-related quality of life (Medical Outcome Short Form, SF-36), effective costs per survivor, and costs per life year and per quality-adjusted life year gained.Of 303 patients, 44 (14.5%) died in the hospital. Among the remaining 259 patients, 190 (73%) survived the 5-yr follow up and 173 patients (91%) completed the questionnaire. Baseline demographics including gender, age, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, simplified Therapeutic Intervention Scoring System, and admission diagnosis were similar between hospital and long-term survivors (p > .05 for all). The health status index of those patients surviving the 5-yr follow-up was 0.88, independent of patients' severity of illness. The average effective costs per survivor were 8.827 for intensive care unit costs and 14.130 for intensive care unit and hospital costs. Mean costs per life year and per quality-adjusted life year gained amounted to 19.330 and 21.922 , respectively. Increasing severity of illness was associated with higher costs. CONCLUSIONS: Considering the severity of illness and the patients' outcome, the costs associated with both life year and quality-adjusted life year gained were within generally accepted limits for other potentially life-saving treatments.     

加强出院后护理对老年糖尿病患者再入院的影响

目的 探讨出院后的护理对老年糖尿病患者再入院的影响。方法 随机将100例糖尿病患者分为对照组和观察组各50例,对照组在住院期间给予常规健康教育及一次性的出院指导,观察组住院期间加强个体化的健康教育,出院后延续健康教育及护理,1年后观察2组病人再入院率情况。结果 观察组病人再入院率与对照组比较,差异有显著性（p〈0．05）,具有统计学意义。结论 加强出院后的护理能提高老年糖尿病人的生活质量,延长患者院外生存时间,减少其入院率。     

High‐value transitional care: translation of research into practice

Objective To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence‐based approach to address the needs of chronically ill older adults throughout acute episodes of illness. Methods A prospective, quasi‐experimental study of 172 at‐risk Aetna Medicare Advantage members in the mid‐Atlantic region who received the TCM. A baseline and post‐intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year. Results Improvements in all health status and quality of life measures were observed post‐ intervention compared to pre‐intervention. Among 155 stringently matched pairs, a significant decrease in number of re‐hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short‐term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037). Conclusions Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real‐world organization and achieve higher value.     

延伸护理对肺癌病人生存质量影响的研究

[目的]评价延伸护理对肺癌病人生存质量的影响。[方法]选取2010年2月—11月入住我院呼吸科的非小细胞肺癌病人70例,根据住院号尾数单双号分为干预组和对照组。干预组于出院后实施延伸护理,对照组不进行延伸护理干预,应用欧洲癌症研究治疗组织(EORTC)开发的癌症病人生存质量测定量表评价两组出院后1个月和3个月时的生存质量。[结果]出院后1个月干预组认知功能和疼痛症状评分优于对照组(P<0.05);3个月后干预组躯体功能、角色功能、认知功能、社会功能、总体健康状况及疼痛、失眠症状得分均优于对照组(P<0.05)。[结论]对肺癌病人实施有计划的延伸护理,可有效改善肺癌病人的生存质量。     

Effects of Post-Discharge Nurse-Led Telephone Supportive Care for Patients with Chronic Kidney Disease Undergoing Peritoneal Dialysis in China: A Randomized Controlled Trial

♦ Background: Patients with end-stage renal failure (ESRF) need integrated health care to maintain a desirable quality of life. Studies suggest that post-discharge nurseled telephone support has a positive effect for patients suffering from chronic diseases. But the post-discharge care is under-developed in mainland China and the effects of post-discharge care on patients with peritoneal dialysis have not been conclusive.♦ Aim: The purpose of this study is to test the effectiveness of postdischarge nurse-led telephone support on patients with peritoneal dialysis in mainland China.♦ Methods: A randomized controlled trial was conducted in the medical department of a regional hospital in Guangzhou. 135 patients were recruited, 69 in the study group and 66 in the control group. The control group received routine hospital discharge care. The study group received post-discharge nurse-led telephone support. The quality of life (Kidney Disease Quality of Life Short Form, KDQOL-SF), blood chemistry, complication control, readmission and clinic visit rates were observed at three time intervals: baseline before discharge (T1), 6 (T2) and 12 (T3) weeks after discharge.♦ Results: Statistically significant effects were found for symptom/problem, work status, staff encouragement, patient satisfaction and energy/fatigue in KDQOL-SF and 84-day (12-week) clinic visit rates between the two groups. The study group had more significant improvement than the control group for sleep, staff encouragement at both T2 and T3, and pain at T2 and patient satisfaction at T3. No significant differences were observed between the two groups for the baseline measures, other dimensions in KDQOL-SF, blood chemistry, complication control, readmission rates at all time intervals and clinic visit rates at the first two time intervals.♦ Conclusions: Post-discharge nurse-led telephone support for patients undergoing peritoneal dialysis is effective to enhance patients’ well-being in the transition from hospital to home in mainland China.Key words: Peritoneal dialysis, nursing, telephone support, discharge, ChinaChronic kidney disease (CKD), especially end-stage renal failure (ESRF) represents a major public health problem in developed and developing countries (1). Healthcare statistics in mainland China show that ESRF has become one of the major health problems in the adult Chinese population (2). Peritoneal dialysis (PD) is a kind of renal replacement therapy (RRT) which is often presented as an easier and less cumbersome dialysis modality (3). However, long-term PD impacts the patient’s physical, psychological and social well-being, leads to frequent re-hospitalization and may impose a considerable burden on patients and families (4), which induces great demands on integrated health and social care to maintain a desirable quality of life, decrease morbidity during the course of the disease and improve health outcomes of ESRF patients (5).In recent decades, studies have shown that post-discharge care using a nurse-led case management model produces a positive effect for patients suffering from chronic diseases (6,7). Some studies have shown that post-discharge nurse-led care can bring about positive outcomes for ESRF patients (8,9). However, these studies were mainly done in Canada, UK, USA and Hong Kong (6-12). China is undertaking a nursing development plan (2011 - 2015) that explores the establishment of a long-term care services system that gradually extends to the family and community for the elderly and those suffering from chronic diseases (Ministry of Health, 2011). Quan et al. and Xu et al., at Peking University, have performed nurse- or physician-led care management on PD patients and have found positive intervention to be helpful for improving PD patients’ compliance with dietary restriction of salt and fluid intake and controlling some complications such as seasonal variation of blood pressure, anemia or hyperphosphatemia (13-15). However, it is not certain whether a similar post-discharge nurse-led care model is effective in the context of mainland China.The aim of this study is to develop an original nurseled telephone support model for peritoneal dialysis patients in mainland China who are discharged from the hospital to home. Furthermore, the effects of the nurseled telephone support program in improving the quality of life and reducing hospital readmission of PD patients were also tested.     

Comprehensive discharge planning for the elderly

Discharge planning for the elderly can potentially reduce patient length of hospital stay, prevent rehospitalization, enhance patient outcomes and lessen the burden of care on the families. While increased numbers of elderly are being discharged earlier, there are few data on the process and effects of discharge planning protocols developed specifically for this population. The proposed study will attempt to answer the following questions regarding hospitalized elderly with selected DRG classifications: Are there significant differences between elderly patients who receive the hospital's general discharge planning procedure used for all categories of patients and elderly who receive the hospital's general discharge planning procedure plus a comprehensive discharge planning protocol specific to the elderly and implemented by a gerontological nurse specialist in: (1) Patient Outcomes (length of initial hospitalization; post-discharge morbidity; post-discharge health services; functional status; mental status; satisfaction with care; self-esteem; patient's perception of health status; and stress level); (2) Family Related Outcomes (primary care giver's functional status; mental status; care giving demands; stress level and family functioning); (3) Cost of Care Outcomes (charges for initial hospitalization, rehospitalizations, post-discharge health services; family related costs; and gerontological nurse specialist costs). The study design is a randomized clinical trial with a total of 280 elderly (2 groups of 140). The control group will receive routine discharge planning; the treatment group will receive routine discharge planning plus an elder-specific comprehensive discharge planning protocol. Data analysis will include frequency distributions and summary statistics. For each of the research questions, multivariate analysis of variance or chi-square statistics will be used.     

The effectiveness of intermediate care in a nursing-led in-patient unit

In order to assess the potential for a nursing-led in-patient unit (NLIU) to substitute for a period of care in the acute hospital environment and promote recovery before discharge, a randomised controlled trial was conducted. The setting was an acute inner London hospital trust, part of the UK's national health service. Of patients referred to a NLIU from acute wards, 80 were randomly assigned to usual care (remain in normal hospital system) and 97 to the NLIU (nursing-led care with no routine medical involvement). Patients were identified as medically stable but in need of additional nursing intervention by referring medical staff prior to full nursing assessment of suitability. Outcomes compared included functional dependence (Barthel Index), discharge destination and length of hospital stay. Inputs from nursing, paramedical and medical staff were measured. There was no significant difference in functional independence at discharge (p0.05). Patients undergoing usual care stayed in hospital for less time (mean difference 18 days, p<0.01) but the same number of patients were in hospital 90 days after recruitment (23% NLIU, 24% usual care p0.05) due to re-admissions. The model of care implemented differed considerably from that described in the literature with the NLIU having significantly fewer qualified nurses (RNs). Although the anticipated benefits of the NLIU were not demonstrated, the study does not conclude that the model should be rejected. Factors driving length of stay need to be further investigated, as does the possibility of post-discharge benefits. The NLIU does offer some potential to substitute for acute care but also appears to substitute for a period of primary care.     

Caregivers of frail rural older adults. Effects of an advanced practice nursing intervention

Informal caregivers are responsible for providing the majority of post-discharge care for many frail older adults in rural settings. The purpose of this study was to investigate whether an advanced practice nurse (APN) intervention would promote more positive physical and emotional outcomes in caregivers of rural older adults who are frail and were recently discharged from urban-based hospitals. Thirty-two caregivers of frail rural elderly individuals were randomly assigned to treatment (APN intervention) and control groups (no APN intervention). Assessments of caregiver outcomes were collected via telephone interviews at 48-hour, 2-week, and 4-week intervals after hospital discharge of the frail rural older adults. Outcomes were operationalized as caregiver physical health and well being, and stress and burden. The former was measured using the Health and Daily Living form (HDL) and the latter by the Thoughts and Feeling and Time and Energy subscales of the Caregiver Burden Inventory (CBI). Additional information on caregiver problems and APN visit time was collected by the APN using the Omaha Classification System. Caregivers in the treatment group experienced significantly more positive physical and emotional health outcomes. The caregivers who received the APN intervention had higher self-rated emotional health scores, fewer emotional symptoms at Week 4, fewer depressive symptoms at Week 2 and 4, and lower Thoughts and Feelings stress scores at 48 hours than the control group. Findings support the importance of addressing the needs of caregivers post-discharge and the ability of APNs to improve post-discharge outcomes for home health care recipients and their caregivers.     

Enhancing postoperative recovery of cardiac surgery patients: a randomized clinical trial of an advanced practice nursing intervention

The purpose of this trial was to determine the effectiveness of advanced practice nursing support on cardiac surgery patients' during the first 5 weeks following hospital discharge. Patients ( N = 200) were randomly allocated to two groups: (a) an intervention group who received telephone calls from an advanced practice nurse (APN) familiar with their clinical condition and care needs, twice during the first week following discharge then weekly thereafter for 4 weeks, and (b) a usual care group. Measures of health-related quality of life (HRQL), symptom distress, satisfaction with recovery care, and unexpected health care contacts were obtained at 5 weeks following discharge. There were no significant group differences in HRQL, unexpected contacts with the health care system, or symptom distress. The provision of APN support via telephone followup after cardiac surgery is feasible. However, further randomized trials of single and multicomponent APN interventions are needed to prove effectiveness.     

Differentiated practice, patient-oriented care and quality of work in a hospital in the Netherlands

This article describes a quantitative study of the relationship between differentiated practice on the one side and patient-oriented care and quality of work on the other. Nursing wards where differentiated practice has been implemented (intervention group) have been compared with wards where differentiated practice has not been implemented (reference group). The research variables with regard to differentiated practice, patient-oriented care and quality of work have been measured by questionnaires. Subjects were 68 nurses and six supervisors from six nursing wards from one hospital. The results show that the extent to which differentiated practice had been implemented varied between the wards. With regard to patient-oriented care differences have been found between the intervention and reference group on the variables patient assignment and use of the nursing process, but not on the variables of tasks and communication. Concerning quality of work, differences have been found on: social support from the supervisor, social-emotional leadership and health complaints. Rank order correlations between differentiated practice and patient-oriented care and between differentiated practice and quality of work were not significant. Practical implications with regard to the use of differentiated practice and implications for further research are discussed.     

电话干预对经皮经肝胆道外引流术患者康复及生活质量的影响

目的探讨电话干预对经皮经肝胆道外引流术治疗恶性梗阻性黄疸患者康复及生活质量的影响。方法将某三级甲等医院经皮经肝胆道外引流术治疗恶性梗阻性黄疸患者分为对照组48例和干预组51例。干预组在接受常规健康教育的基础上,出院后3个月内接受电话干预提供的个性化健康教育;出院后3个月对两组患者带管相关知识、带管相关并发症及生活质量进行调查比较。结果患者出院后3个月除引流袋更换外,电话干预组带管相关知识均优于对照组,生活质量优于对照组,带管相关并发症低于对照组(P<0.01或P<0.05)。结论电话干预可以提高经皮经肝胆道外引流术治疗梗阻性黄疸患者的自我护理能力及生活质量。     

The cost-effectiveness of intensive postdischarge care. A randomized trial

This study tested the hypothesis that increasing the intensity of outpatient care for patients discharged from the hospital could lower their subsequent inpatient and total health-care costs. At discharge, 1,001 patients were stratified by risk of readmission (low, medium, or high) and randomly assigned to the intervention or control group. Discharge information (summaries, medications, and postdischarge needs) was provided to outpatient nurses who monitored intervention patients closely and attempted to resolve their problems. Intervention patients also received appointment reminders, and missed visits were promptly rescheduled. The cost of the intervention was $5.20 per patient per month. High-risk patients in the intervention group had significantly higher outpatient costs ($131/month vs. $107/month; P = 0.02), but lower inpatient costs ($535/month vs. $800/month; P = 0.02) than high-risk patients in the control group. Reduced inpatient costs in the high-risk intervention group were attributed to shorter, less intensive hospital stays. In conclusion, increasing ambulatory care resources after hospital discharge for high-risk patients may reduce health-care costs associated with readmission to the hospital.     

Components of a proper hospital discharge for elders

SIGNIFICANCE: Effective discharge planning is a vital link in continuity of care for elders. Previous studies identify problems with planning for elders' discharge from the hospital and problems elders encounter managing care post-discharge. However, little attention has been given to identifying effective discharge planning processes. Explicating the components of effective discharge planning is critical to replicate the process in other health care settings and predict post-discharge outcomes. PURPOSE: The purpose of this study was to identify the components of effective discharge planning for elders and factors that impede planning. METHODS: Ethical approvals were obtained from the University and National Health Service (NHS) Trust. Qualitative methods were used and data were collected from two wards in a 78-bed geriatric rehabilitation hospital that was part of a National Health Service Trust serving Southwest London. Data included semi-structured interviews and documents related to discharge planning, care delivery, and community resources. A total of 24 semi-structured interviews were conducted with health care professionals who were part of the hospital's multidisciplinary team, those affiliated with the Community Trust that provided aftercare, elders, and family carers. RESULTS: Participants consistently used the term "proper discharge" when referring to effective discharge planning. The multidisciplinary team comprised a vital context for a proper discharge. The findings indicated that three circles of communication were central in a four stage discharge process. Different circles of communication were key at different stages. CONCLUSIONS: The findings provide insights for educating nurses about effective planning practices and examining the global significance of impediments to a proper hospital discharge.     

A call to arms to reduce premature deaths by using inexpensive resuscitation care

Two hundred seventy thousand people in the US and 450,000 people in Europe experience out-of-hospital cardiac arrest each year. Perceived poor prognosis and expense of care of patients resuscitated from cardiac arrest remain barriers to implementation of effective therapies. In this issue of Critical Care, Graf and colleagues have provided a programmatic evaluation of the costs and consequences of intensive care after resuscitation from cardiac arrest. Thirty-one percent of the cohort that survived to be cared for in the intensive care setting were still alive 5 years after hospital discharge. The health-related quality of life of this group of 5-year survivors was similar to that of matched healthy controls, and the cost per quality-adjusted life year gained was similar to or less than the cost of other commonly used medical interventions. We need to change the culture of resuscitation and recognize that cardiac arrest is a treatable condition that is associated with acceptable quality of life and costs of care after resuscitation.     

Partners in care: a model of collaboration

It is estimated that 3 million persons in the United States have congestive heart failure. This diagnosis accounts for more than 5% of total health expenditures. A method to decrease the costs of health care was initiated through the partners-in-care model of collaborative practice. A research study exploring the use of nurse case managers in collaboration with cardiologists and primary care physicians is being conducted with persons older than 65 years. This care encompasses both inpatient and outpatient care. The intervention comprises nurse visits in the hospital and in the home as well as telephone support for 6 months after the index hospitalization. The outcomes of quality of life, functional status, mortality, morbidity, and costs are being examined. Collaborative health care partnerships may be an effective strategy to decrease health care costs and improve quality of life and functional status of older persons with congestive heart failure.     

A comparison of Gordon's functional health patterns model and standard nursing care in symptomatic heart failure patients: A randomized controlled trial

BackgroundHeart failure (HF) is associated with poor quality of life and increased morbidity and mortality.AimThis study aimed to investigate effect of application of Gordon's functional health pattern (FHP) model in nursing care of symptomatic HF patients on quality of life, morbidity and mortality in the post-discharge 30-day.MethodsThis is a prospective randomized controlled study conducted in a single center. Experimental group received nursing care planned in accordance with Gordon's FHP model. 60 control and 60 experimental HF patients were included in the study. In the control group nursing care was given according to the standard protocol of the hospital whereas in the experimental group nursing care was given in accordance with Gordon's FHP model. Patients in both groups were followed up after discharge at 30th day.ResultsMean Minnesota Living with Heart Failure Questionnaire score improved significantly in the experimental group compared to the control group at 30th day (40.2 ± 23.5 vs 62.3 ± 22.9 respectively, p = 0.001). Seven patients (11.7%) in the experimental group and 17 patients (28.3%) in the control group were readmitted in the post discharge 30-day (p = 0.02). Kaplan-Meier survival curve analysis revealed significant difference in 30-day event free survival rates between groups (log-rank p = 0.31).ConclusionApplication of Gordon's FHP model in the nursing care of HF patients was associated with significantly improved quality of life, and reduced hospital readmission rates at 30th day. This was the only independent predictor of 30-day event free survival.     

A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure

Aims and objectives. To evaluate the effectiveness and cost‐effectiveness of a community nurse‐supported hospital discharge programme in preventing hospital re‐admissions, improving functional status and handicap of older patients with chronic heart failure. Design. Randomized controlled trial; 105 hospitalized patients aged 60 years or over with chronic heart failure and history of hospital admission(s) in previous year were randomly assigned into intervention group (n = 49) and control group (n = 56) for six months. Intervention group subjects received community nurse visits before discharge, within seven days of discharge, weekly for four weeks, then monthly. Community nurse liaised closely with a designated specialist in hospital and were accessible to subjects during normal working hours. Control and intervention group subjects were followed up in the same specialist medical clinics. Primary outcome was the rate of unplanned re‐admission at six months. Secondary outcomes were number of unplanned re‐admissions, six‐minute walking distance, London Handicap Scale and public health care and personal care costs. Results. At sixth months, the re‐admission rates were not significantly different (46 vs. 57% in control subjects, p = 0·233, Chi‐square test). But the median number of re‐admissions tended to lower in the intervention group (0 vs. 1 in control group, p = 0·057, Mann Whitney test). Intervention group subjects had less handicap in independence (median change 0 vs. 0·5 in control subjects, p = 0·002, Mann Whitney test), but there was no difference in six‐minute walking distance. There was no significant group difference in median total public health care and personal care costs. Conclusion. Community nurse‐supported post‐discharge programme was effective in preserving independence and was probably effective in reducing the number of unplanned re‐admissions. The cost benefits to public health care were not significant. Relevance to clinical practice. Older chronic heart failure patients are likely to benefit from post‐discharge community nurse intervention programmes. More comprehensive health economic evaluation needs to be undertaken.