Will
a Discharge Follow-up Nurse Decrease Readmissions for Pediatric Asthma
Patients?

April
Hernandez

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Chamberlain
College of Nursing

NR451
RN Capstone Course

January
2018

 

Will
a Discharge Follow-up Nurse Decrease Readmission for Pediatric Asthma Patients?

Asthma
is one of the most common chronic pediatric diseases. Asthma is a chronic
inflammatory disorder of the airways marked by episodes of respiratory distress
that is reversible. Distress is caused by airway narrowing and obstruction. Pediatric
Asthmatic patients can have episodes that vary from mild to severe, even fatal.

According to Healthypeople2020, “Daily preventive treatment can prevent
symptoms and attacks and enable individuals who have asthma to lead active
lives” (2017). Discharge instructions and follow-up are key for patient safety and
quality of care, to reduce unnecessary emergency department readmissions within
30 days of discharge. Respiratory issues, including asthma, pneumonia and acute
bronchitis rank number 1 in the top 10 reasons for pediatric emergency
department visits.

According to Cochrane database of systemic
reviews, case manager led discharge plans can prevent hospitalization and
readmissions for pediatric asthma patients (Hall, Chang & O’Grady, 2016). Reports show that using a
discharge follow-up nurse to call patients and families after discharge improves
the quality of life of patients, reduces hospital admissions, and reduces overall
patient and hospital expense (Stavrianopoulos,
2016). In the Emergency Department (ED), many pediatric
patients return to the ED with asthma exacerbation within 30 days. Often
patients return to the ED within a few days or weeks. Determining a way to help
patients manage their asthma related diagnosis at home before returning to the
ED will benefit patients and the hospital.  A new designated discharge follow-up call nurse, assigned to
each pediatric patient and family discharged with asthmatic related illness,
may improve the hospitals ability to offer support and education to these
patients and their families, improving quality of care, reducing rate and
frequency of exacerbations, and prevent readmissions within 30 days of
discharge.

 

Change Model Overview

The ACE Star model of Knowledge Transformation is an approach for
translating research into practice bringing together components of several
disciplines with the goal of quality improvement. The model is a five-point
star, has five steps of knowledge that represent 1) discovery, 2) summary of
evidence, 3) translation of that evidence, 4) the integration of change into practice
and 5) evaluation of the change of practice (Chamberlain College of Nursing,
2017). According to Stevens, “The ACE Star Model
emphasizes crucial steps to convert one form of knowledge to the next and
incorporate best research evidence with clinical expertise and patient
preferences thereby achieving EBP” (2013). 

Nurses should use
this model as a guide to facilitate change. This is evidenced by hospital data
and national data. The ACE Star Model uses research that represents
evidence-based practice and applies it to the nursing issue so that the nurse
can be confident when implementing the new change practice.

Define the Scope of the EBP

The hospital has a problem
with frequent revisits and readmissions of pediatric asthmatic patients to the
emergency department after discharge within 30 days or much less with symptoms
of the same asthma related diagnosis.  According
to Healthcare Finance many California hospitals have received a 3.0% penalty in
Medicare reimbursements in 2015 and 2016 for readmissions within 30 days. This
was an analysis of federal data by Kaiser Health News (Readmission rates by
hospital/state, 2016).

Through feedback surveys and actual readmission data, it
has been discovered that these patients and families do not retain information
provided during the visit and at discharge. Hospital admission rates for acute
asthma exacerbation are at 18% in America. Reducing the frequency of acute
exacerbations, or recurrent exacerbation after discharge should be an important
goal. If discharge instruction and planning is effective, recurrence of acute
asthma exacerbation would decrease, as well as readmissions. Asthma is the most
common chronic childhood disease. It affects 9 million children in the united
states, approximately 4 million experience asthma exacerbation annually, and
1.8 million ED visits yearly. Medicaid programs in 2010 report $272 million was
spent on pediatric asthma ED visits. Readmission rates to ED after acute asthma
visits are 10% within 2 weeks following the initial visit (Johnson, Chambers,
Dexheimer, 2016). The goal of this Evidence-based Practice (EBP) change
plan is to reduce the number of pediatric asthma by 15% within 3 months with
the use of an individualized discharge Nurse that will call pediatric asthma
patient’s family after discharge, to answer any questions the patient and/or
family has about asthma, treatment plan, medications, and help develop a plan
of care with the family for home treatment and follow-up intervention. This
would be a significant decrease in readmission/revisits to the emergency
department for KOMC.

Stakeholders

There are quite a
few stakeholders in the change plan. The team will be made up of a nurse
leader, ED Physician, the nurse director, the charge nurse, a discharge
follow-up call nurse, the nurse educator, the nursing informatics specialist,
and the nursing staff on the unit.

Determine Responsibility of Team Members

The nurse leader
will be responsible for organizing the team members and directing the change
plan. The director of nursing will be responsible for communication with
administration and emergency department physicians to ensure they are on board,
the emergency physician will be responsible to help create the standardized discharge
nurse call follow-up form so that it will be structured and protocol orders
will be in place the nurse is acting within scope of practice.  The charge nurse will ensure that the staff
and emergency department physician fill out the discharge form for the
discharge follow-up call nurse. The nurse educator will be in charge of creating
learning 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, and
the form that needs to be completed by the emergency department physician. The discharge
follow-up call nurse will be responsible for calling the patients after
discharge to answer any questions the patient and/or family has about asthma,
treatment plan, medications, and help develop a plan of care with the family
for home treatment and follow-up intervention. The nursing informatics
specialist will be responsible for loading the tool in the HER for collecting
data regarding calls made, calls connected with patients and number of
readmissions after calls made versus, readmissions without calls made. The
nursing staff on the unit will be responsible to make sure the form is
completed by the emergency physician.

Evidence

Several articles
that included randomized controlled trials with children less than 18 years old
admitted to the hospital with acute respiratory exacerbation were
systematically reviewed. It was determined that discharge caseworkers reduce
re-admission of people with chronic respiratory conditions through the
following ways “a) facilitating the discharge plan and
obtaining needed consultations from other allied health services as required;
b) collaborating with home health agencies; and c) providing educational
information and emotional support to the child and family” (Hall, Chang, &
O’Grady, 2016). Patients
who understand their discharge instructions clearly, including medication
administration and when to make follow-up appointments, are 30 percent less
likely to be readmitted or visit the emergency department than patients who are
unclear and unaware (“Reducing hospital readmissions”, 2018). Telephone support
is inexpensive, easy, requires minimal resources, and provides care and
supports the individual needs of all patients immediately after discharge from
hospital, reducing likelihood of readmission (Stavrianopoulos, 2016). Research
showed that patients who received a call after discharge to answer follow-up
questions and who completed the intervention suggested by nurse were
significantly less likely to be readmitted compared to those who did not
(Harrison et al, 2014). The BRN interprets RN scope of practice to
include telephone nursing and telephone triage (“RN Tele-nursing”, 2011). “It
is incumbent upon the RN to be knowledgeable and competent in the practice when
offering telephonic assessment, evaluation, referral, or advice to patients or
their family members” (“RN Tele-nursing”, 2011).

Summarize the Evidence

Evidence shows that
not only are financial penalties an issue with readmissions, they can be very
expensive, and possibly harmful to the patient, including missed work/school, loss
of time with family, and risk for hospital acquired infections. Preventing a readmission
saves the hospital money and improves the health of the patient in the long
term. 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 saves
the hospital money (Stavrianopoulos,
2016). A patient who understands discharge instructions is 30 percent less
likely to be readmitted or visit the emergency department than patients who are
unclear and unaware (“Reducing hospital readmissions”, 2018). Evidenced based research shows that nurse initiated phone
call shortly after discharge significantly reduced hospital readmissions by
resolving issues such as clarifying aftercare instructions, issues with
obtaining outpatient appointments, issues with prescriptions, questions
regarding medications, new or exacerbation of symptoms (Mourad & Rennke, 2012).

Develop Recommendations for Change Based on Evidence

After reviewing
the literature on discharge plans to prevent hospital readmission for acute
exacerbations in children with asthma (Hall, Chang & O’Grady, (2016), Harrison
et al (2014), Johnson, Chambers,
& Dexheimer (2016), Mourad
& Rennke, (2012) Stevens, (2013)). The recommendation is to
implement a discharge nurse to call and follow-up with pediatric patients
discharged with asthma related illness to prevent emergency department revisits/readmissions.

Translation

Action Plan

The nurse leader
will be responsible for organizing the team members, directing the change plan
and encouraging administration and emergency physicians to back the change plan.

The director of nursing will be responsible for communication with
administration and emergency department physicians and emergency department
about the trial change plan. The emergency physician will be responsible to
help create the standardized discharge nurse call follow-up form so that it
will be structured and protocol orders will be in place the nurse is acting
within scope of practice.  The charge
nurse will ensure that the staff and emergency department physician fill out
the discharge form for the discharge follow-up call nurse. The emergency
department nurse educator will train the staff personally and using learning
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, and the
form that needs to be completed by the emergency department physician. The discharge
follow-up call nurse will be responsible for calling the patients after
discharge to answer any questions the patient and/or family has about asthma,
treatment plan, medications, and help develop a plan of care with the family
for home treatment and follow-up intervention. The nursing informatics
specialist will be responsible for loading the tool in the EHR for collecting
data regarding calls made, calls connected with patients and number of
readmissions after calls made versus, readmissions without calls made. The
nursing staff on the unit will be responsible to make sure the form is
completed by the emergency physician.

Timeline

By April 1: All the team members will
be selected, Emergency department Physician Director, and Director of nursing
will be involved and prepared to implement the change plan. The nurse leader,
quality improvement leader, will gather baseline data of pediatric asthma
related illness readmissions.

By April 10: Nurse educator will
have prepared training modules. Training will begin in the emergency
department. The discharge follow-up form will be created and shared with staff
during education. Informatics specialist will upload the tool to collect data.

By April 22: Emergency department
staff education will be complete. Trail change plan will begin. Emergency
department physicians will begin filling out the forms for discharged pediatric
asthma patients. Discharge follow-up call nurse will begin making calls post
discharge. Data will be collected by nurse leader (QI leader) using the
informatics tool.

By April 30: Data will be analyzed
to determine how many forms were filled out, how many calls were made, how many
patients were contacted and how many readmissions took place. There will be a
meeting once a week to discuss improvement and need for any adjustments.

July 10: Sum of pediatric asthma
related illness readmissions over the past 3 months will be evaluated and used
to determine if there is substantial evidence to continue the change plan.  If it is found that there is not enough
evidence after three months and the results are inconclusive, the change plan
trial will be extended for three more months.

Process, Outcomes Evaluation and Reporting

The desired
outcome of this change plan would be at least 15% reduction of revisits/readmissions
of pediatric asthmatic patients to the emergency department. This would show
that the change plan was successful. It would indicate that resources allocated
to change the discharge follow-up process were a positive investment. Reducing
readmits by 15% could have a substantial financial impact for the hospital, and
a 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 informatics
tool in EHR as well as patient surveys. From this data, the change plan team
will determine how many forms were filled out, how many calls were made, how
many patients were contacted and how many readmissions took place, and
subsequently if there was a reduction in readmissions.

The results will
be reported to the stakeholders in administration at the charge nurse meeting
(emergency physician, nursing director, managers, nurse educator and charge
nurses attend) by the nurse leader. The will also be reported in the shift
huddle before each shift as well as at staff meetings.

Identify Next Steps

The plan for using
a discharge follow-up call nurse for pediatric asthmatic patients to prevent
readmissions will be determined by how successful it was. If data indicates substantial
decrease in readmissions over 3 to 6 months, the change plan can be implemented
on other discharge diagnoses with high readmission rates such as congestive
heart failure. This would be done by using the same format that was used for pediatric
asthmatic patients. Staff and team will already be educated on the discharge process,
therefore it will be an easy implementation. This discharge follow-up call
nurse change plan should become a permanent change by administration, if the
data reflects at least 15% decrease in hospital readmissions.

Disseminate Findings

The results will
be reported to the stakeholders in administration at the charge nurse meeting
(emergency physician, nursing director, managers, nurse educator and charge
nurses attend) by the nurse leader. The will also be reported in the shift
huddle before each shift as well as at staff meetings. The hospital has a
website and newsletter for members where positive outcomes and news can be
shared. The public relations department can also contact local newspapers like
the Daily Bulletin to share the progress of the new change plan.

Conclusion

Effective discharge planning
can decrease the risk of recurrent acute exacerbations of chronic disease with
or without readmission to hospital (Hall, Chang & O’Grady, 2016). A
systematic review of evidence-based practice on discharge plans to prevent
hospital readmissions for acute exacerbation in children with chronic
respiratory illness, such as asthma. It was determined that caseworker-assigned
discharge plans versus discharge plans that do not involve caseworker support
reduce the rate and frequency of exacerbation requiring emergency department
visits or hospitalization (Hall, Chang & O’Grady,
2016). By implementing an individualized discharge follow-up nurse to
call pediatric asthma patient’s family after discharge, to answer any questions
the patient and/or family has about asthma, treatment plan, medications, and to
help develop a plan of care with the family for home treatment and follow-up
intervention, it is expected that readmission rates will decrease by 15% from
hospitals baseline. The ACE Star Model is based on best practice research and
clinical practice and was used to aide in putting the new discharge change plan
in effect in the emergency department. Using the ACE Star Model, which is
highly esteemed in nursing practice, to integrate evidence into practice, strengthens
the results of this trial change plan, so it can be used in this hospitals and
others as well. The trial will begin with discharged pediatric asthma patients
and other patient diagnoses will be considered after the 3 to 6 month trial
period. During this 3 to 6 months, readmission data and use of discharge form
and discharge follow-up nurse will be evaluated by QI staff. Additional
training will be provided if needed.

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