A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

BACKGROUND: Emergency department visits and rehospitalization are common after hospital discharge. OBJECTIVE: To test the effects of an intervention designed to minimize hospital utilization after discharge. DESIGN: Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card. SETTING: General medical service at an urban, academic, safety-net hospital. PATIENTS: 749 English-speaking hospitalized adults (mean age, 49.9 years). INTERVENTION: A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment. MEASUREMENTS: Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment. RESULTS: Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed. LIMITATION: This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report. CONCLUSION: A package of discharge services reduced hospital utilization within 30 days of discharge. FUNDING: Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.

Evidence-based practice, clinical simulations workshop, and intravenous medications: moving toward safer practice.

In an era of increased emphasis on medication safety practice, a gap exists in the translation of research to clinical practice for administering intravenous continuous infusion medications. An educational initiative was designed for medical-surgical nurses in a tertiary care center to standardize operational procedures in a clinical model focusing on evidence-based practice.

Revisiting Project Re-Engineered Discharge (RED): The Impact of a Pharmacist Telephone Intervention on Hospital Readmission Rates.

PURPOSE: Project Re-Engineered Discharge is a discharge nurse education (DNE) and pharmacist follow-up telephone intervention protocol that was shown to decrease rehospitalization significantly. The specific value of the pharmacist intervention was not originally evaluated. The objective of this study was to determine the impact of a pharmacist telephone intervention during the transition of care process on the rate of unplanned hospitalization within 30 days of patient discharge. METHODS: A retrospective chart review was completed for patients who received DNE counseling and were discharged to home from the family medicine service at Boston Medical Center from July 2012 to May 2013. Patients were stratified into two groups: contacted/intervention and unable to contact/no intervention. The primary outcome was the rate of unplanned hospital utilization including emergency department visits and readmissions within 30 days of discharge. Secondary end points included number of pharmacist interventions and time spent on phone calls. RESULTS: A total of 401 patients were identified; 277 patients received a pharmacist telephone intervention, and 124 patients were unable to be contacted. Baseline characteristics did not differ between the two groups, with the exception of a higher prevalence of substance abuse in the nonintervention group (41.9% vs 21.3%, p<0.001). The rate of unplanned hospitalization (visits/patient) was significantly reduced in the intervention group, compared with the unable-to-contact group (0.227 vs 0.519, p<0.001). Pharmacists made a total of 128 interventions and spent an average of 22 minutes on each telephone intervention. CONCLUSION: Patients unable to be contacted by a pharmacist after hospital discharge were more likely to be readmitted or visit the emergency department in the 30 days following discharge. A pharmacist telephone intervention as part of a comprehensive discharge protocol can have a positive impact on patients during the transition of care process by reducing incidence of unplanned hospital utilization.

Physicians' pain management confidence versus competence.

OBJECTIVE: To assess awareness of existing pain management guidelines and compare physicians' confidence versus competence in selected pain management skills. DESIGN: Prospective survey study. SETTING: A large urban tertiary medical center. PATIENTS, PARTICIPANTS: All Department of Medicine interns, senior residents, and attending physicians were sent a questionnaire; the overall response rate was 30 percent (91/304). INTERVENTIONS: The questionnaire assessed physicians' awareness of the institution's pain management guidelines, their self-reported comfort level (confidence) with, and a knowledge assessment (competence) of three pain management skills (managing chronic-continuous pain, equianalgesic dose conversion, and managing breakthrough pain) using validated, standardized case vignettes. MAIN OUTCOME MEASURES: A comparison of physicians' confidence with their competence in these pain management skills. RESULTS: A total of 23 percent (21/91) of the respondents reported an awareness of the institution's pain management guidelines. Interns were significantly less confident than senior residents in all three pain management skills (p < 0.001, 0.006, 0.02) but nonsignificantly more competent in two of three skills (chronic-continuous pain, dose conversion). Attendings were generally more confident and nonsignificantly more competent than senior residents in all three pain management skills. CONCLUSIONS: The underutilization of the pain management guidelines illustrates that the mere existence of these resources as a means of ensuring optimal pain management is insufficient. Creative pain management educational initiatives are needed to address the disparity between physician confidence and competence.