Abstract

The problem is extended wait times among paediatric patients at the selected Paediatric Emergency Department (PED). This is a result of failure by nurses and clinicians to effectively educate patients at discharge, which causes many patients to return for complications listed in their discharge instructions. The extended wait times lead to patient dissatisfaction and poor organizational outcomes as patients may leave without care. Hospital readmission within 30 days of discharge remain a serious health concern in the US. Statistics indicate that 1 in five Medicaid patients return to hospital within 30 days of discharge. Cumulatively, readmissions alone account for approximately $42 billion in health spending annually. A literature review was conducted to gather evidence-based knowledge on strategies for enhancing the effectiveness of discharge procedures. Evidence was gathered by searching for US-based primary research articles in the JAMA Network, Cochrane Open Access, the Directory of Open Access Journals, and the Digital Commons Network published within the past five years. Systematic reviews and meta-analyses, as well as older articles, were excluded, but were kept as reference material and used in the narrative review. The evidence showed that effective pre-discharge education and post-discharge follow-up significantly reduced hospital revisits. Based on this evidence, the project seeks to reduce patient wait times at the PED by adopting an enhanced discharge education program that includes post-discharge follow-up phone calls. The project faces cost constraints given the large number of patients, time limitations, as it has to be completed within the given time frame, and the risk that staff may resist change.

Key words: discharge education, revisits, readmission

Background to the Problem

Every year, over 35 million discharges occur across the United States hospital network (Alper et al., 2022). The process of discharging a patient from hospital is complicated as it makes families and patients responsible for coordinating care. In an ideal transition of care, the healthcare provider prepares the patient by adequately communicating crucial discharge information on medication, side effects, and when to make follow-ups, guided by the patients health status and health literacy levels (Bajorek & McElroy, 2020). Studies have associated effective discharge education with greater medication compliance, and lower readmission and mortality risks (Boden-Alballa et al., 2018; dejong et al., 2020). For instance, dejong et al. (2020) found that a quality improvement bundle that included enhanced discharge information and follow-up reduced readmission rates in a pediatric hospital from 10 percent to 7.4 percent over a four-month period.

Unfortunately, healthcare providers may not always be in a position to predict a patients discharge day. So in most cases, discharges are done in an unstandardized and rushed manner on the day of discharge (Bajorek & McElroy, 2020). Patients mostly receive a bulk of new information that is explained in a rushed manner, with little consideration for health status and health literacy levels (Boden-Alballa et al., 2018). In most cases, healthcare providers use health-related jargon to explain medication side effects and indications, which patients may not understand or may find difficult to remember (Boden-Alballa et al., 2018). Emergency Department (ED) patients and caregivers will often receive discharge information across four domains: ED-based care, diagnosis and cause, instructions on when to return, and post-ED care (Boden-Alballa et al., 2018). In one study, researchers interviewed 140 English-speaking caretakers and patients upon release from the emergency department (ED) to assess how well they understood the discharge instructions they had received (Boden-Alballa et al., 2018). The study found that less than 15 percent of respondents had understood all four domains of ED discharge instructions (Boden-Alballa et al., 2018).

Unfortunately, poor understanding of discharge instructions is associated with unintended hospital revisits, a greater risk of readmission, and decreased patient satisfaction (Boden-Alballa et al., 2018). Statistics indicate that 1 in five Medicaid patients in the US return to hospital within 30 days of discharge. Cumulatively, readmissions alone account for approximately $42 billion in health spending annually.

Problem Statement

The main problem at the selected PED is extended wait times resulting from increases in the number of patients returning within two weeks of discharge. According to the nurse manager at the PED, over 65 percent of patients return within 14 days of discharge for complications listed in their discharge instructions or concerns expected in their diagnosis within the time frame of letting it run its course, such as fever. The primary reason is that providers and nurses are not taking the time to effectively use discharge tools and educate patients at discharge. The result has been declining patient dissatisfaction as shown by quarterly patient surveys. Patients have had to wait as long as four hours and the management is concerned that if the problem is not addressed, it could result in aggrieved patients leaving without care.

Resolution Strategy

Bajorek and McElroy (2020) identify certain risk factors that drive poor transitions and delivery of discharge education in healthcare settings. First, healthcare providers often rush the discharge process, overestimating the patients health literacy needs, social determinants, and readiness to learn (Bajorek & McElroy, 2020). Further, caregivers or family members may not be adequately involved in the discharge planning and education efforts (Bajorek & McElroy, 2020). As such, they may not understand the medication names, side effects, indications, diagnosis, and even the reasons or mechanisms for scheduling an appointment for their patient (Bajorek & McElroy, 2020). A third risk factor is that discharge instructions and education are often provided by different healthcare provders, who may use different health-related terms and wordings, causing confusion among patients (Bajorek & McElroy, 2020).

Strategies that address these factors could be categorized into post-discharge, pre-discharge, and bridging interventions (Alper et al., 2022). Post-discharge interventions include medication reconciliation, discharge planning, patient education, and scheduling of follow-up appointments (Alper et al., 2022). Common post-discharge interventions include home visits and regular follow-up phone calls; while bridging interventions include clinician continuity between outpatient and inpatient settings and use of transition coaches (Alper et al., 2022).

The purpose of the proposed project is to reduce the number of reoccurring visits resulting from ineffective discharge instructions by 50% over the next six months through implementing a program that incorporates enhanced pre-discharge education and post-discharge follow-up phone calls. The projected goal is to reduce patient wait times to less than one hour, thus reducing the number of patients who leave without care, and ultimately increasing patient satisfaction.

The project uses the IOWA model of Evidence-Based Practice to promote the proposed intervention. The IOWA model was selected for two reasons....

…of patients were returning to the hospital within 1 month of discharge for failing to understand instructions given during discharge. As such, it would be beneficial to identify evidence-based interventions that could help solve the problem.

Selection of Research Evidence

The second step in the IOWA model involved searching for available evidence on possible strategies, appraising the evidence, and selecting the most appropriate evidence for extending quality care to patients (Cullen et al., 2022). At this stage, six full articles were analyzed, from which four primary research articles (levels IV to VII of evidence) were ruled feasible in guiding practice. Most of the available evidence focuses on pre-discharge education and post-discharge follow-up calls, and hence, these were selected as the most plausible interventions for the proposed project.

Applying Evidence in Practice

In the third step of the IOWA model, the team applies the selected interventions in practice. The first step involved setting objectives (purpose) and determining the overall project goal. Thereafter, the healthcare providers will be trained on how to offer enhanced discharge education by considering a patients culture, literacy levels, and health needs. The session will also focus on sharing knowledge around the identified problem, the implementation plan, IOWA model, the selected evidence-based interventions, and the targeted outcomes. The healthcare providers will then use the guide they receive during the training to prepare patients for discharge

Evaluation

The project will be evaluated on the basis of impact, relevance, sustainability, and efficacy. An impact evaluation would gather relevant information about the impact or observed changes that could be attributed to the strategy implemented. Effectiveness would assess whether the objectives of the strategy were achieved. Relevance would assess how well the project objectives align with the organizational objectives, while sustainability would assess the likelihood of the change being sustained beyond the project period given the available resources.

Integrate the Evidence-Based Change in Routine Practice

The final step is to integrate the evidence-based change into routine practice. This would begin with a dissemination workshop where the findings of the project as well as the way forward would be communicated. To help integrate the interventions into routine practice, the management could develop a discharge education guideline that would standardize performance and adopt the use of enhanced education techniques as standard discharge procedure. Other strategies for sustainability could include offering regular in-service training for both existing and new staff to ensure proper utilization of the guideline.

Conclusion

In conclusion, the proposed project seeks to address the problem of extended wait times resulting from increased reoccurring visits due to lack of proper patient education on previous discharge. According to the nurse manager, discharges are mostly carried out in a rushed manner and patients often receive loads of new information, which they are unable to memorize. The result is a large number of reoccurring visits for concerns expected in patients diagnosis within the time frame of letting it run its course, such as fever. This results in extended wait times that leads to patient dissatisfaction. The project seeks to streamline the discharge process by implementing an enhanced discharge education and post-discharge call-back program at the PED. The purpose of the proposed project is to reduce the number of reoccurring visits resulting from ineffective discharge instructions by 50%…