Discharge Planning: Comparison of Patients'and Nurses'Perceptions of Patients Following Hospital Discharge

Planning for hospital discharge is an important component of nursing. Results are presented of a study to determine how well primary nurses predict the functional ability of their patients following discharge and to assess whether patients and nurses agree about their patients' understanding of the post-discharge treatment plan. Comparing nurses' predictions with patients' reports of functional status 2 months following discharge, we found that nurses consistently underestimate the functional ability of their patients. Comparing nurses' perceptions of their patients' understanding of their post-discharge treatment plan with patients' reports about their understanding, significant differences were found between nurses' perceptions and patients' reports. Nurses' perceptions were that patients were much more knowledgeable than their patients reported. These preliminary data suggest that hospital discharge planning is an area for further investigation and intervention. Nurses should explore new paradigms for patient education as lengths of hospital stay decrease and care shifts from acute care to community care.     

Randomized trial of an intensive care unit-based early discharge planning intervention for critically ill elderly patients.

BACKGROUND: Few investigators have targeted elderly patients and monitored outcomes of care in studies on discharge planning interventions after critical illness. OBJECTIVES: To pilot test an intensive care unit-based nursing screening intervention to assist in determining the discharge needs and outcomes of critically ill elderly patients. METHOD: A randomized clinical trial with in-hospital and mailed questionnaires was used. Patients 65 years and older who were hospitalized in 1 of 2 intensive care units at 2 midwestern university-affiliated medical centers were recruited for the study. Control patients (n = 53) received usual discharge planning, experimental patients (n = 47) were screened in the intensive care unit by using the Discharge Planning Questionnaire. Both groups were assessed for readiness for discharge when discharged from the hospital and were followed up 2 weeks later with a survey completed at home. RESULTS: One hundred patients 65 to 90 years old (mean 73, SD 5.78) completed the study. Sixty-six percent were men. The 2 groups did not differ with regard to age, race, sex, severity of illness, lengths of stay in the intensive care unit or hospital, education level, or income. Patients in the experimental group were more ready than patients in the control group for discharge (P =.06). Patients in the experimental group were also more likely to report they had adequate information, had less concern about managing their care at home, knew their medicines, and knew danger signals indicating potential complications. CONCLUSION: Intensive care unit-based early discharge planning can affect elderly patients' preparation for discharge.     

Geriatric versus general medical wards: comparison of patients'' behaviours following discharge from an acute care hospital

The objective of this study was to explore, from a nursing perspective, the effectiveness of geriatric wards in preparing elderly patients for discharge from an acute care hospital. A convenience sample of 40 patients aged 70 years or older was obtained from three geriatric medical wards and two general medical wards of a large British teaching hospital. Data were collected immediately prior to discharge, and after 6 and 13 weeks following discharge. No meaningful differences were found between the two patient-groups in their ability to cope with activities of daily living following discharge. The majority of deaths and/or hospital readmissions occurred within 6 weeks of discharge. A major concern identified in both groups was patients' lack of knowledge about medications and their side-effects. A need for more effective teaching programmes for elderly patients was identified.     

Participation of informal caregivers in the hospital care of elderly patients and their evaluations of the care given: pilot study in three different hospitals

This action research is an ongoing study which will last from 1991 to 1993. The main purpose of the study is to increase the participation of informal caregivers in the hospital care of elderly patients without decreasing the quality of care. The data reported here are from a pilot study. This study had three aims: (a) to test reliability and validity of the measure used, (b) to investigate the current participation of informal caregivers in the hospital care of elderly patients (aged over 75), and (c) to evaluate and compare the quality of care from both the patients' and the informal caregivers' point of view in three different hospitals. The measure of quality of care was developed on the basis of need theories, mainly those of Maslow and Alderfer. Patients and caregivers were also asked to rate the participation of the caregivers in the hospital care of elderly patients. Participation consisted of 18 activities of daily living. The pilot test with 18 elderly hospital patients and seven family members or significant others showed differences between the two groups in perception of care received. Statistically significant differences (P < 0.001) were found in the following categories: mainly social needs, psychic and spiritual needs and totals. The results supported earlier findings that elderly patients are satisfied with and do not criticize their care. The younger generation (i.e. their children) is more demanding and has precise perceptions about the care given. Relatives could be used more in planning, evaluation and even implementation of care; however, their current participation in patient hospital care is minimal.     

Hospital stay and discharge outcomes after knee arthroplasty

The impact of shorter hospital lengths of stay on patient outcomes at discharge from acute care after knee arthroplasty was investigated in a prospective observational outcome study at three Melbourne public hospitals during a 5-month period from October 1999 to March 2000. The participants were 105 consecutive patients (35 at each hospital), with a mean age of 71 years. Outcome measures were length of stay, destination (home or rehabilitation) and functional mobility at discharge from the acute care facility. During the study period mean hospital length of stay across the three hospitals was 6.5 days, more than 30% less than the Victorian average for the preceding year. This was associated with high rates of discharge to rehabilitation facilities (mean 64%), with rates varying between the three hospitals (97%, 57% and 40%). However, in each hospital, one-third of this group had already achieved a level of independent functional mobility adequate for discharge home, highlighting an apparent influence of non-clinical factors on discharge decisions, including pressure to decrease length of stay, hospital policy and availability of a rehabilitation bed. Ways of achieving discharge directly home for a greater number of patients following knee arthroplasty and of determining optimal length of stay are discussed.     

Length of stay in community hospitals

AIM: To identify the factors that contribute to variation in length of stay in hospital. METHOD: After a pilot study, an audit was undertaken in 11 community hospitals in a single trust over an eight-week period. Each ward was audited once. During the audit period 202 patients' records were reviewed, of which 71 were GP admissions and 131 were consultant admissions. RESULTS: Patients admitted to community hospitals were older, predominantly female, classed as at risk of malnutrition and had a reduced functional capacity. An increased length of stay could also be due to limited evidence of discharge planning on transfer from acute or residential homes, a lack of information about patients' social circumstances and how the discharge process was progressed, delay from referral to assessment by the multidisciplinary team, and pressure ulcers on admission to hospital. CONCLUSION: Recommendations for practice are: improved documentation, including an integrated discharge care pathway that is transferable across health and social care; multidisciplinary records; clinical leadership; adapting the current audit tool; and undertaking another audit after the recommendations have been implemented.     

Mortality rate and length of stay of patients admitted to the intensive care unit in July

OBJECTIVE: At the beginning of each academic year in July, inexperienced residents and fellows begin to care for patients. This inexperience can lead to poor patient outcome, especially in patients admitted to the intensive care unit (ICU). The objective of this study was to determine the impact of July ICU admission on patient outcome. DESIGN: Retrospective, cohort study. SETTING: Academic, tertiary medical center. PATIENTS: Patients admitted to the ICU from October 1994 through September 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, Acute Physiology and Chronic Health Evaluation (APACHE) III score and predicted mortality, admission source, admission date, intensity of treatment, ICU length of stay (LOS), and hospital mortality of 29,084 patients were obtained. The actual and predicted weighted ICU LOS and their ratio were calculated. Logistic regression analysis was used to compare the hospital mortality rate of patients admitted to the ICU in July with those admitted during the rest of the year, with adjustment for potentially confounding variables. The patients' mean age was 62.3 +/- 17.6 yrs; 57.3% were male and 95.5% white. Both the customized predicted and observed hospital mortality rates of the entire cohort were 8.2%. The majority (76.7%) of the patients were discharged home, and 15.1% were discharged to other facilities. When adjusted for potentially confounding variables, ICU admission in July was not associated with higher hospital mortality rate compared with any other month. There were no significant differences in the discharge location of patients between July and any one of the other months. There were no statistically significant differences in the weighted ICU LOS ratio between July and any of the other months. CONCLUSIONS: ICU admission in July is not associated with increased hospital mortality rate or ICU length of stay.     

Nursing Diagnoses of Burned Patients and Relatives' Perceptions of Patients' Needs

PURPOSE.  The aims of this study were to identify the nursing diagnoses of burn patients in the period 1 week before hospital discharge and to determine whether their relatives had similar perceptions of the patients' problems.
METHODS.  A qualitative case study was conducted with 10 burn patients and 10 family members. One week before hospital discharge, the nursing diagnoses of the patients and the relatives' perceptions of the patients' were identified and compared.
FINDINGS.  Thirty different diagnoses related to physical and psychosocial aspects were identified. The family members reported concerns mainly related to physical care, specifically wound care and prevention of infection, and psychosocial aspects, while patients were primarily concerned with the latter.
CONCLUSIONS.  Nursing diagnoses for these patients and their relatives' perceptions frequently overlapped; however, the emphasis of the families' attention was on the physical aspects.
IMPLICATIONS FOR NURSING PRACTICE.  Anticipating family members' perceptions about the patients' problems is important in order to promote strategies that will improve patient care after hospital discharge.     

Survivors of catastrophic illness: outcome after direct transfer from intensive care to extended care facilities

OBJECTIVE: To describe outcomes of adult survivors of prolonged critical illness after direct transfer to extended care facilities. DESIGN: A retrospective cohort study. SETTING: All adult intensive care units (ICUs) in a tertiary care university hospital. PATIENTS: A consecutive series of 97 adult survivors with an ICU stay of > or =7 days transferred directly from intensive care to extended care facilities between 1990 and 1996. INTERVENTIONS: None. METHODS AND MAIN RESULTS: Hospital and extended care facility charts were reviewed for patient characteristics, resource utilization, and survival. Survivors were for a minimum of 1 yr and a maximum of 6 yrs, and were interviewed to assess quality of life and functionality. The mean age of the patients was 66+/-16 (range, 19-93) yrs. The median length of ICU stay for these patients was 39 (range, 7-276) days. Only 18 of the 71 ventilator-assisted patients were weaned from mechanical ventilation after transfer to the extended care facility. Survival for the study period, at 1 yr after discharge from the ICU, was 49.5%. One year after discharge from the ICU, 11.5% of all patients had returned home, were breathing spontaneously, had a fair or better quality of life, and had good physical functionality. Each successive year, an increasing proportion of patients underwent direct transfer to an extended care facility. This strategy decreased the patients' length of stay (p<.002) in the ICU from year to year, but was significantly associated with an increase in readmissions to acute care hospitals (p<.002). CONCLUSIONS: Survivors of catastrophic illness who are so debilitated that they require transfer to an extended care facility have a low likelihood of achieving both survival and functional independence 1 yr after discharge from the ICU. Aggressive cost-conscious strategies to accelerate the transfer of these patients successfully reduced the length of ICU stay and hospital costs, but were associated with a high rate of readmission to tertiary care facilities.     

脑卒中患者住院时间和出院去向相关影响因素的研究

目的运用研究影响脑卒中患者住院时间以及出院后的去向的相关因素,为实施干预及提高患者的生活质量提供理论依据。方法调查204例住院患者住院时间和出院后去向,以及其影响因素,通过统计学方法分析各因素对住院时间和出院后去向的影响。结果脑梗死患者比脑出血患者年龄大,121例患者出院后回家休养,36例送到康复医院,47例又到其他医院住院;中等和大面积的梗塞、脑出血、日常生活活动能力(ADL)评分低和出院去向明显相关;在出院回家的患者中,低ADL评分与住院时间明显相关;丈夫患病住院时间相对较短,而妻子患病住院时间相对较长。结论患者的家庭构成和性别以及中风的程度对住院时间和出院去向有明显影响。     

Effects of admission to a nursing unit

This paper describes the results of a study of elderly patients admitted to hospital with fractured neck of femur, cerebral vascular accident or amputation of a lower limb who were, immediately post-crisis, transferred to a unit where nursing was perceived as the chief therapeutic activity. Patients' outcomes were compared with a control group who followed a normal patient pathway, either remaining in an acute hospital ward until discharge or being transferred to a community hospital for part of their stay. The study was a modified replication of a small pilot study carried out between 1983 and 1985.     

The quality of intraoperative nursing care: the patient's perspective

The purpose of this study was to document patients' responses (n = 246) to intraoperative care and to find out whether or not their opinions (n = 158) changed with time Another goal was to develop a patient-based scale for continuous systematic evaluation The data were collected by a structured questionnaire in two phases in 1993 first at the end of the patients' hospital stay, and then after a few weeks at home The following themes were covered in the questionnaire biological-physiological, experiential, cognitive, functional, ethical, the characteristics and competence of nursing professionals, and environmental Statistical analysis suggested that the patients were satisfied with their intraoperative care Problems occurred mainly in cognitive and experiential perspectives, such as the need for continuous access to information and coping with the anxiety related to the impending surgery It also emerged that special attention must be paid to keeping the patient warm in the operating theatre and to looking after emergency patients, younger patients, and patients who only remain in the operating department for a short period of tune The patients' evaluations of the standards of care tended to be less critical in hospital than they were a few weeks after discharge     

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE: The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN: A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING: Seventeen-bed adult MICU. PATIENTS: Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS: Palliative care consultations. MEASUREMENTS AND MAIN RESULTS: Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS: Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.     

A qualitative study of the information needs of acute myocardial infarction patients, and their preferences for follow-up contact after discharge.

BACKGROUND: Several studies have claimed that patients have unmet information needs after discharge following acute myocardial infarction (AMI). Our overall goal is to develop a post-discharge nursing intervention program to provide patients with appropriate information and support in contexts where existing follow-up services are poorly developed. AIMS: To explore the information needs of inpatients with AMI and their preferences for follow-up contact after discharge from hospital. METHODS: Fourteen AMI patients aged 42-69 years participated in one of three focus groups, held between 3 and 5 months after their discharge. RESULTS AND CONCLUSIONS: The findings are grouped into three themes corresponding to the major topics in the interview guide: the hospital stay, coming home, and patients' follow-up preferences. The data support the findings of previous studies that there is a systemic failure to meet patients' in-hospital and post-discharge information needs. Most importantly, our participants' follow-up preferences favoured open telephone lines and telephone follow-up. The results of this study provide some of the knowledge that is necessary to improve patient information and support following AMI.     

The patient's signature of the physician's report at discharge from rehabilitation

What follows for the outcome of rehabilitation, patients' satisfaction and work organisation in a rehabilitation hospital if the patients obtain their discharge reports for signature before they leave? This has been investigated in a pilot study at the University Rehabilitation Hospital in Bad Wurzach, Germany. The pilot study was so successful that the hospital continued to use the new procedure. Only very few refused their signature, most patients were happy to obtain their discharge reports immediately and to have the opportunity to discuss the report with their physician if desired. Physician judged patients' participation slightly more pointly while the known discrepancies between physicians' and patients' point of view remained, i. e. the physician doesn't "touch up" knowing the patient will read his report. Integrating the patient in the process is a major step towards patients' empowerment. Both the influence on patients' satisfaction and changes in work organisation are discussed in the paper. A timely discharge examination and an optimised computer-supported workflow, transformation of loosely coupled activities in a process managed by time frames are preconditions for being able to have the discharge report ready before the patients leave. Monitoring the timely delivery then becomes obsolete.     

23-hour care centre: changing the culture of care.

AIM: A 23-hour Care Centre was created at a principal referral hospital in Sydney in 2003. Its primary aim was to provide efficient and high quality care to patients requiring a brief stay in hospital for surgical or medical procedures, within one coordinated unit. DESIGN: The features underlying the 23-hour Care Centre as an innovative model of care were the clinical guideline driven approach and nurse-initiated discharge. All patients, emergency and elective as well as surgical and medical, who fitted the following criteria were admitted as '23-hour patients' to the Centre. The criteria were: absolute expectation of discharge within 24 hours; pre-admission screening by a nurse screener (if elective admission); agreed clinical guideline in place; and, agreement to protocol-based, nurse-initiated discharge. RESULTS: Following the first three months of the 23-hour Care Centre, 1601 patients utilised the 23-hour Care Centre as follows: 593 day only patients, 410 DOSA (day of surgery admission) patients and 598 23-hour patients. Excluding inappropriate admissions, overall discharge compliance was 83%. CONCLUSION: From the results generated throughout the trial it has become evident that the new clinical area offers a workable system of health care delivery for patients who require a brief stay in hospital, as it promotes an efficient use of hospital beds and services without compromising patient outcomes. However, further research is required to compare the efficiency and outcomes of care directly with that provided by the traditional inpatient hospital system.