Willa Discharge Follow-up Nurse Decrease Readmissions for Pediatric AsthmaPatients?AprilHernandezChamberlainCollege of NursingNR451RN Capstone CourseJanuary2018 Willa Discharge Follow-up Nurse Decrease Readmission for Pediatric Asthma Patients?Asthmais one of the most common chronic pediatric diseases. Asthma is a chronicinflammatory disorder of the airways marked by episodes of respiratory distressthat is reversible. Distress is caused by airway narrowing and obstruction. PediatricAsthmatic patients can have episodes that vary from mild to severe, even fatal.According to Healthypeople2020, “Daily preventive treatment can preventsymptoms and attacks and enable individuals who have asthma to lead activelives” (2017).

Discharge instructions and follow-up are key for patient safety andquality of care, to reduce unnecessary emergency department readmissions within30 days of discharge. Respiratory issues, including asthma, pneumonia and acutebronchitis rank number 1 in the top 10 reasons for pediatric emergencydepartment visits. According to Cochrane database of systemicreviews, case manager led discharge plans can prevent hospitalization andreadmissions for pediatric asthma patients (Hall, Chang & O’Grady, 2016). Reports show that using adischarge follow-up nurse to call patients and families after discharge improvesthe quality of life of patients, reduces hospital admissions, and reduces overallpatient and hospital expense (Stavrianopoulos,2016). In the Emergency Department (ED), many pediatricpatients return to the ED with asthma exacerbation within 30 days. Oftenpatients return to the ED within a few days or weeks. Determining a way to helppatients manage their asthma related diagnosis at home before returning to theED will benefit patients and the hospital.  A new designated discharge follow-up call nurse, assigned toeach pediatric patient and family discharged with asthmatic related illness,may improve the hospitals ability to offer support and education to thesepatients and their families, improving quality of care, reducing rate andfrequency of exacerbations, and prevent readmissions within 30 days ofdischarge.

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 Change Model OverviewThe ACE Star model of Knowledge Transformation is an approach fortranslating research into practice bringing together components of severaldisciplines with the goal of quality improvement. The model is a five-pointstar, has five steps of knowledge that represent 1) discovery, 2) summary ofevidence, 3) translation of that evidence, 4) the integration of change into practiceand 5) evaluation of the change of practice (Chamberlain College of Nursing,2017). According to Stevens, “The ACE Star Modelemphasizes crucial steps to convert one form of knowledge to the next andincorporate best research evidence with clinical expertise and patientpreferences thereby achieving EBP” (2013).

 Nurses should usethis model as a guide to facilitate change. This is evidenced by hospital dataand national data. The ACE Star Model uses research that representsevidence-based practice and applies it to the nursing issue so that the nursecan be confident when implementing the new change practice.

Define the Scope of the EBP The hospital has a problemwith frequent revisits and readmissions of pediatric asthmatic patients to theemergency department after discharge within 30 days or much less with symptomsof the same asthma related diagnosis.  Accordingto Healthcare Finance many California hospitals have received a 3.0% penalty inMedicare reimbursements in 2015 and 2016 for readmissions within 30 days. Thiswas an analysis of federal data by Kaiser Health News (Readmission rates byhospital/state, 2016).

Through feedback surveys and actual readmission data, ithas been discovered that these patients and families do not retain informationprovided during the visit and at discharge. Hospital admission rates for acuteasthma exacerbation are at 18% in America. Reducing the frequency of acuteexacerbations, or recurrent exacerbation after discharge should be an importantgoal. If discharge instruction and planning is effective, recurrence of acuteasthma exacerbation would decrease, as well as readmissions. Asthma is the mostcommon chronic childhood disease.

It affects 9 million children in the unitedstates, approximately 4 million experience asthma exacerbation annually, and1.8 million ED visits yearly. Medicaid programs in 2010 report $272 million wasspent on pediatric asthma ED visits. Readmission rates to ED after acute asthmavisits are 10% within 2 weeks following the initial visit (Johnson, Chambers,Dexheimer, 2016). The goal of this Evidence-based Practice (EBP) changeplan is to reduce the number of pediatric asthma by 15% within 3 months withthe use of an individualized discharge Nurse that will call pediatric asthmapatient’s family after discharge, to answer any questions the patient and/orfamily has about asthma, treatment plan, medications, and help develop a planof care with the family for home treatment and follow-up intervention. Thiswould be a significant decrease in readmission/revisits to the emergencydepartment for KOMC.StakeholdersThere are quite afew stakeholders in the change plan.

The team will be made up of a nurseleader, ED Physician, the nurse director, the charge nurse, a dischargefollow-up call nurse, the nurse educator, the nursing informatics specialist,and the nursing staff on the unit. Determine Responsibility of Team MembersThe nurse leaderwill be responsible for organizing the team members and directing the changeplan. The director of nursing will be responsible for communication withadministration and emergency department physicians to ensure they are on board,the emergency physician will be responsible to help create the standardized dischargenurse call follow-up form so that it will be structured and protocol orderswill be in place the nurse is acting within scope of practice.  The charge nurse will ensure that the staffand emergency department physician fill out the discharge form for thedischarge follow-up call nurse. The nurse educator will be in charge of creatinglearning modules on KP learn to ensure that the staff understands the process,the rational of the change plan so that they will encourage the process, andthe form that needs to be completed by the emergency department physician. The dischargefollow-up call nurse will be responsible for calling the patients afterdischarge to answer any questions the patient and/or family has about asthma,treatment plan, medications, and help develop a plan of care with the familyfor home treatment and follow-up intervention.

The nursing informaticsspecialist will be responsible for loading the tool in the HER for collectingdata regarding calls made, calls connected with patients and number ofreadmissions after calls made versus, readmissions without calls made. Thenursing staff on the unit will be responsible to make sure the form iscompleted by the emergency physician. EvidenceSeveral articlesthat included randomized controlled trials with children less than 18 years oldadmitted to the hospital with acute respiratory exacerbation weresystematically reviewed.

It was determined that discharge caseworkers reducere-admission of people with chronic respiratory conditions through thefollowing ways “a) facilitating the discharge plan andobtaining needed consultations from other allied health services as required;b) collaborating with home health agencies; and c) providing educationalinformation and emotional support to the child and family” (Hall, Chang, &O’Grady, 2016). Patientswho understand their discharge instructions clearly, including medicationadministration and when to make follow-up appointments, are 30 percent lesslikely to be readmitted or visit the emergency department than patients who areunclear and unaware (“Reducing hospital readmissions”, 2018). Telephone supportis inexpensive, easy, requires minimal resources, and provides care andsupports the individual needs of all patients immediately after discharge fromhospital, reducing likelihood of readmission (Stavrianopoulos, 2016). Researchshowed that patients who received a call after discharge to answer follow-upquestions and who completed the intervention suggested by nurse weresignificantly less likely to be readmitted compared to those who did not(Harrison et al, 2014). The BRN interprets RN scope of practice toinclude telephone nursing and telephone triage (“RN Tele-nursing”, 2011). “Itis incumbent upon the RN to be knowledgeable and competent in the practice whenoffering telephonic assessment, evaluation, referral, or advice to patients ortheir family members” (“RN Tele-nursing”, 2011).Summarize the Evidence Evidence shows thatnot only are financial penalties an issue with readmissions, they can be veryexpensive, and possibly harmful to the patient, including missed work/school, lossof time with family, and risk for hospital acquired infections.

Preventing a readmissionsaves the hospital money and improves the health of the patient in the longterm. Medicare & Medicaid Services now publicly report hospitals’risk-adjusted 30-day readmission rates for specific diagnoses on its Web site,Hospital Compare (http://www.hospitalcompare.hhs.gov). (Mourad & Rennke, 2012).

A discharge phone call is low cost and savesthe hospital money (Stavrianopoulos,2016). A patient who understands discharge instructions is 30 percent lesslikely to be readmitted or visit the emergency department than patients who areunclear and unaware (“Reducing hospital readmissions”, 2018). Evidenced based research shows that nurse initiated phonecall shortly after discharge significantly reduced hospital readmissions byresolving issues such as clarifying aftercare instructions, issues withobtaining outpatient appointments, issues with prescriptions, questionsregarding medications, new or exacerbation of symptoms (Mourad & Rennke, 2012).Develop Recommendations for Change Based on EvidenceAfter reviewingthe literature on discharge plans to prevent hospital readmission for acuteexacerbations in children with asthma (Hall, Chang & O’Grady, (2016), Harrisonet al (2014), Johnson, Chambers,& Dexheimer (2016), Mourad& Rennke, (2012) Stevens, (2013)). The recommendation is toimplement a discharge nurse to call and follow-up with pediatric patientsdischarged with asthma related illness to prevent emergency department revisits/readmissions.TranslationAction PlanThe nurse leaderwill be responsible for organizing the team members, directing the change planand encouraging administration and emergency physicians to back the change plan.The director of nursing will be responsible for communication withadministration and emergency department physicians and emergency departmentabout the trial change plan.

The emergency physician will be responsible tohelp create the standardized discharge nurse call follow-up form so that itwill be structured and protocol orders will be in place the nurse is actingwithin scope of practice.  The chargenurse will ensure that the staff and emergency department physician fill outthe discharge form for the discharge follow-up call nurse. The emergencydepartment nurse educator will train the staff personally and using learningmodules on KP learn to ensure that the staff understands the process, therational of the change plan so that they will encourage the process, and theform that needs to be completed by the emergency department physician. The dischargefollow-up call nurse will be responsible for calling the patients afterdischarge to answer any questions the patient and/or family has about asthma,treatment plan, medications, and help develop a plan of care with the familyfor home treatment and follow-up intervention. The nursing informaticsspecialist will be responsible for loading the tool in the EHR for collectingdata regarding calls made, calls connected with patients and number ofreadmissions after calls made versus, readmissions without calls made. Thenursing staff on the unit will be responsible to make sure the form iscompleted by the emergency physician.

TimelineBy April 1: All the team members willbe selected, Emergency department Physician Director, and Director of nursingwill be involved and prepared to implement the change plan. The nurse leader,quality improvement leader, will gather baseline data of pediatric asthmarelated illness readmissions.By April 10: Nurse educator willhave prepared training modules.

Training will begin in the emergencydepartment. The discharge follow-up form will be created and shared with staffduring education. Informatics specialist will upload the tool to collect data.By April 22: Emergency departmentstaff education will be complete. Trail change plan will begin. Emergencydepartment physicians will begin filling out the forms for discharged pediatricasthma patients. Discharge follow-up call nurse will begin making calls postdischarge. Data will be collected by nurse leader (QI leader) using theinformatics tool.

By April 30: Data will be analyzedto determine how many forms were filled out, how many calls were made, how manypatients were contacted and how many readmissions took place. There will be ameeting once a week to discuss improvement and need for any adjustments. July 10: Sum of pediatric asthmarelated illness readmissions over the past 3 months will be evaluated and usedto determine if there is substantial evidence to continue the change plan.  If it is found that there is not enoughevidence after three months and the results are inconclusive, the change plantrial will be extended for three more months.Process, Outcomes Evaluation and Reporting The desiredoutcome of this change plan would be at least 15% reduction of revisits/readmissionsof pediatric asthmatic patients to the emergency department. This would showthat the change plan was successful. It would indicate that resources allocatedto change the discharge follow-up process were a positive investment.

Reducingreadmits by 15% could have a substantial financial impact for the hospital, anda significant increase in quality of care for the patients and their families.The outcomes would be measured by number of readmits gathered from QI and informaticstool in EHR as well as patient surveys. From this data, the change plan teamwill determine how many forms were filled out, how many calls were made, howmany patients were contacted and how many readmissions took place, andsubsequently if there was a reduction in readmissions. The results willbe reported to the stakeholders in administration at the charge nurse meeting(emergency physician, nursing director, managers, nurse educator and chargenurses attend) by the nurse leader. The will also be reported in the shifthuddle before each shift as well as at staff meetings. Identify Next StepsThe plan for usinga discharge follow-up call nurse for pediatric asthmatic patients to preventreadmissions will be determined by how successful it was.

If data indicates substantialdecrease in readmissions over 3 to 6 months, the change plan can be implementedon other discharge diagnoses with high readmission rates such as congestiveheart failure. This would be done by using the same format that was used for pediatricasthmatic patients. Staff and team will already be educated on the discharge process,therefore it will be an easy implementation.

This discharge follow-up callnurse change plan should become a permanent change by administration, if thedata reflects at least 15% decrease in hospital readmissions. Disseminate FindingsThe results willbe reported to the stakeholders in administration at the charge nurse meeting(emergency physician, nursing director, managers, nurse educator and chargenurses attend) by the nurse leader. The will also be reported in the shifthuddle before each shift as well as at staff meetings.

The hospital has awebsite and newsletter for members where positive outcomes and news can beshared. The public relations department can also contact local newspapers likethe Daily Bulletin to share the progress of the new change plan. ConclusionEffective discharge planningcan decrease the risk of recurrent acute exacerbations of chronic disease withor without readmission to hospital (Hall, Chang & O’Grady, 2016). Asystematic review of evidence-based practice on discharge plans to preventhospital readmissions for acute exacerbation in children with chronicrespiratory illness, such as asthma.

It was determined that caseworker-assigneddischarge plans versus discharge plans that do not involve caseworker supportreduce the rate and frequency of exacerbation requiring emergency departmentvisits or hospitalization (Hall, Chang & O’Grady,2016). By implementing an individualized discharge follow-up nurse tocall pediatric asthma patient’s family after discharge, to answer any questionsthe patient and/or family has about asthma, treatment plan, medications, and tohelp develop a plan of care with the family for home treatment and follow-upintervention, it is expected that readmission rates will decrease by 15% fromhospitals baseline. The ACE Star Model is based on best practice research andclinical practice and was used to aide in putting the new discharge change planin effect in the emergency department. Using the ACE Star Model, which ishighly esteemed in nursing practice, to integrate evidence into practice, strengthensthe results of this trial change plan, so it can be used in this hospitals andothers as well.

The trial will begin with discharged pediatric asthma patientsand other patient diagnoses will be considered after the 3 to 6 month trialperiod. During this 3 to 6 months, readmission data and use of discharge formand discharge follow-up nurse will be evaluated by QI staff. Additionaltraining will be provided if needed. References American NursesAssociation (ANA). (2015). Nursing: Scope and standards ofpractice (3rd ed.

). Silver Spring, MD: Author.Chamberlain College of Nursing. (2017). Week 1: RNCapstone {Online Lesson}. Downers             Grove,IL.Hall, K.

K., Chang, A. B.,& O’Grady, K.

F. (2016). Discharge plans to prevent hospital readmission foracute exacerbations in children with chronic respiratory illness (Protocol).

Cochrane Database of Systematic Reviews,Issue 8. Art. No.: CD012315. DOI: 10.1002/14651858.CD012315.

Harrison, J.,D., Auerbach,A.,D., Quinn, K.

, Kynoch, E., Mourad, M. (2014). Assessing             the impact of nurse post-discharge telephone calls on30-day hospital             readmission rates. Journalof General Internal Medicine. Nov. 29(11).

Retrieved             fromhttps://www.ncbi.nlm.nih.

gov/pmc/articles/PMC4238208/Healthy People.gov (2017).Respiratory diseases.  Retrieved from             https://www.healthypeople.gov/2020/topics-objectives/topic/respiratory-diseasesJohnson, L.

H., Chambers, P., Dexheimer, J. W.

(2016).Asthma-related emergency department             use:current perspectives. Open AccessEmergency Medicine: OAEM. 8, 47-55. Doi:             10.2147/OAEM.S69973Mourad, M.

Rennke, S. (2012). Postdischargefollow-up phone call. US Department of Health and Human Services. Retrieved from https://psnet.ahrq.

gov/webmm/case/263/postdischarge-follow-up-phone-callReadmission rates byhospital/state. (2016). Retrieved from             http://www.healthcarefinancenews.com/news/see-which-hospitals-will-be-hit-            readmission-penalties-2016-dataReducing hospital readmissions with enhanced patienteducation. FierceHealthcare Custom Publishing.

Retrieved January 11, 2018 from https://www.bu.edu/fammed/projectred/publications/news/krames_dec_final.pdf(2011). RN Tele-nursing and telephone triage.Board of Registered Nursing.

Retrieved January             18,2018 from http://www.rn.ca.gov/pdfs/regulations/npr-b-35.

pdfStevens, K., R. (2013). The impact of evidence-basedpractice in nursing and the next             bigideas.

 Online Journal of Issues in Nursing, 18(2), manuscript 4.             doi:10.3912/OJIN.Vol18No02Man04.