scholarly journals Role of Transitional Care Measures in the Prevention of Readmission After Critical Illness

2017 ◽  
Vol 37 (1) ◽  
pp. e10-e17 ◽  
Author(s):  
Jessica S. Peters
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Critical Care Unit ◽  
Transitional Care ◽  
Discharge Planning ◽  
Surgical Care ◽  
Care Needs ◽  
Readmission Rates ◽  
Increased Risk ◽  
Poor Outcomes

Transitioning from the critical care unit to the medical-surgical care area is vital to patients’ recovery and resolution of critical illness. Such transitions are necessary to optimize use of available hospital resources to meet patient care needs. One in 10 patients discharged from the intensive care unit are readmitted to the unit during their hospitalization. Critical care readmission is associated with significant increases in illness acuity, overall length of stay, and health care costs as well as a potential 4-fold increased risk of mortality. Patients with complex illness, multiple comorbid conditions, and a prolonged initial stay in the critical care unit are at an increased risk of being readmitted to the critical care unit and experiencing poor outcomes. Implementing nurse-driven measures that support continuity of care and consistent communication practices such as critical care outreach services, transitional communication tools, discharge planning, and transitional care units improves transitions of patients from the critical care environment and reduces readmission rates.

Hospital Readmission and Post-Acute Care Use After Intensive Care Unit Admissions: New ICU Quality Metrics?

2020 ◽  
pp. 088506662095663
Author(s):  
Christopher F. Chesley ◽  
Michael O. Harhay ◽  
Dylan S. Small ◽  
Asaf Hanish ◽  
Hallie C. Prescott ◽  
...  
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Acute Care ◽  
Hospital Readmission ◽  
Critical Care Unit ◽  
Readmission Rates ◽  
Critical Care Units ◽  
Icu Admission ◽  
Over Time ◽  
Post Acute Care

Objective: Care coordination is a national priority. Post-acute care use and hospital readmission appear to be common after critical illness. It is unknown whether specialty critical care units have different readmission rates and what these trends have been over time. Methods: In this retrospective cohort study, a cohort of 53,539 medical/surgical patients who were treated in a critical care unit during their index admission were compared with 209,686 patients who were not treated in a critical care unit. The primary outcome was 30-day all cause hospital readmission. Secondary outcomes included post-acute care resource use and immediate readmission, defined as within 7 days of discharge. Results: Compared to patients discharged after an index hospitalization without critical illness, surviving patients following ICU admission were not more likely to be rehospitalized within 30 days (15.8 vs. 16.1%, p = 0.08). However, they were more likely to receive post-acute care services (45.3% vs. 70.9%, p < 0.001) as well as be rehospitalized within 7 days (5.2 vs. 6.0%, p < 0.001). Post-acute care use and 30-day readmission rates varied by ICU type, the latter ranging from 11.7% after admission in a cardiothoracic critical care unit to 23.1% after admission in a medical critical care unit. 30-day readmission after ICU admission did not decline between 2010 and 2015 (p = 0.38). Readmission rates declined over time for 2 of 4 targeted conditions (heart failure and chronic obstructive pulmonary disease), but only when the hospitalization did not include ICU admission. Conclusions: Rehospitalization for survivors following ICU admission is common across all specialty critical care units. Post-acute care use is also common for this population of patients. Overall trends for readmission rates after critical illness did not change over time, and readmission reductions for targeted conditions were limited to hospitalizations that did not include an ICU admission.

Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Janet Prvu Bettger ◽  
Sara Jones ◽  
Anna Kucharska-Newton ◽  
Janet Freburger ◽  
Walter Ambrosius ◽  
...  
Keyword(s):  
Transitional Care ◽  
Discharge Planning ◽  
Care Transitions ◽  
Cluster Randomized Trial ◽  
Stroke Patients ◽  
Care Needs ◽  
Post Discharge ◽  
Exact Test ◽  
Chi Squared

Background: Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals. Methods: Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test. Results: As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals. Conclusion: Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.

Abstract 097: Effects of BRIDGE Attendance on the Outcomes of Diabetic Patients

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Caitlin Fette ◽  
Rachel Krallman ◽  
Colin McMahon ◽  
Daniel Montgomery ◽  
Jennifer Wang ◽  
...  
Keyword(s):  
Transitional Care ◽  
Care Program ◽  
Primary Diagnosis ◽  
Lower Mortality ◽  
Diabetic Patients ◽  
Post Discharge ◽  
Readmission Rates ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Discharge Outcomes

Background: Prior studies have shown that patients with diabetes mellitus (DM) have increased risk for developing cardiovascular disease. BRIdging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program for patients who have been recently discharged following a cardiac event. Previous research has shown BRIDGE to be effective in improving patient outcomes. This study sought to describe differences in outcomes 1) of heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF) patients with and without concomitant DM, and 2) between diabetic patients who did and did not attend BRIDGE. Methods: Retrospective data were abstracted for HF, ACS, and AF patients from 2008-2014. Patients were divided into cohorts based on presence or absence of DM and BRIDGE attendance versus non-attendance. Outcomes (readmissions, ED visits, death) within each primary diagnosis (HF, ACS, AF) were compared between DM and non-DM patients and between those who attended BRIDGE versus those who did not for all DM patients. Results: Of 2197 patients referred to BRIDGE, 723 (32.9%) had concomitant DM. DM patients had similar outcomes to non-DM patients for most post-discharge outcomes; however, DM ACS patients had higher readmission (42.2% v 29.6%, p<0.001) and death (10.5% v. 4.5%, p=0.001) rates within 6 months, and DM AF patients had higher readmission rates within 6 months (52.1% v 37.9%, p=0.006). HF patients with DM who attended BRIDGE had lower mortality rates within 6 months of discharge than those who did not (10.3% vs. 22.1%, p=0.014). No other significant differences in outcomes were seen between BRIDGE attendees and non-attendees. Conclusions: Though not significant, patients with DM had worse post-discharge outcomes than those without DM for all primary diagnoses. In the subset of DM patients, the 30-day readmission rate for ACS patients who attended BRIDGE was half of those who did not attend. Conversely, 30-day readmission rates for HF patients were greater if they attended. This may in part explain the significantly lower mortality rate among BRIDGE attenders with HF, where patients who needed readmission were identified during their BRIDGE appointment. Due to the high prevalence of DM, efforts to tailor transitional care for this population are needed.

Maternal critical care

2020 ◽  
pp. 2701-2705
Author(s):  
Rupert Gauntlett
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Death Rate ◽  
Critical Care Unit ◽  
Post Partum ◽  
The United Kingdom ◽  
The World ◽  
Resource Poor ◽  
Acute Fatty Liver

Critical illness during pregnancy or after giving birth is rare: in the United Kingdom 0.29% of maternities involve admission to a critical care unit, and the maternal death rate is 0.01%. Over 80% of obstetric admissions to critical care occur in the post-partum phase, mainly due to complications relating to massive haemorrhage. Other pregnancy specific conditions that may require critical care support include pre-eclampsia (typically when diagnosis and treatment have been delayed), amniotic fluid embolism, peri-partum cardiomyopathy, and acute fatty liver of pregnancy. Puerperal sepsis remains a major problem in resource-poor parts of the world. Pregnant women who survive critical illness may be particularly prone to long-term psychological morbidity. It is vital that, once physiological stability has been achieved, no time is wasted before a mother is reunited with her baby.

Neural and endocrine function in the immune response to critical illness

2016 ◽  
Author(s):  
Gareth L. Ackland
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Evolutionary Biology ◽  
Clinical Syndrome ◽  
Therapeutic Interventions ◽  
Endocrine Function ◽  
Flight Response ◽  
Increased Risk ◽  
Fight Or Flight Response ◽  
Fight Or Flight

The neurohormonal physiological response to various stressors is pivotal for maintaining homeostasis. However, the advent of modern critical care has distorted evolutionary biology by generating the entirely new (patho)physiological entity of critical illness. By extending the biological features of the ‘fight or flight’ response beyond the acute phase, distinct neurohormonal, and immune profiles have become increasingly apparent. Both direct and off-target effects of neurohormonal control on immune function are implicated in the disruption of bidirectional links between neurohormones and immune effectors that limit organ dysfunction. Iatrogenic factors introduced by critical care therapy may exacerbate neurohormonal dysregulation, further distorting the biology of the ‘fight or flight’ response. Neural mechanisms underlying this newly-characterized clinical syndrome remain poorly understood. Furthermore, the same neurohormonal responses are chronically dysregulated in pre-existing comorbidities diseases associated with an increased risk of sepsis, multi-organ failure and critical illness. Off-target local immune effects may explain the failure of clinical trials aimed at altering systemic neurohormonal physiology. Recent laboratory and translational human clinical studies, particularly in diseases characterized by chronic neurohormonal dysregulation, have provided new insights into the possibility of therapeutic interventions that could minimize the pathophysiological features of critical illness.

The patient within the critical care environment

2017 ◽  
Author(s):  
Sheila Adam ◽  
Sue Osborne ◽  
John Welch
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Infection Control ◽  
Critically Ill Patients ◽  
Critical Care Unit ◽  
Holistic Approach ◽  
Care Environment ◽  
The Common ◽  
Prolonged Stress ◽  
Dying Patient

Both critical illness and treatment in the critical care unit are extremely stressful, presenting great physical and psychological challenges for patients and their families. There are a range of compensatory responses to stress which may be adaptive, but severe or prolonged stress can induce a destructive spiral of decompensation. The importance of a holistic approach to care cannot be overemphasized; this chapter sets out the priorities of care for critically ill patients, and the common needs and problems for both patients and their families. The issues discussed include the mechanisms of stress in critical illness, the promotion of sleep, use of analgesia and sedation, management of delirium, complications of immobility, mouth, eye, and skin care, infection control, requirements for safe transfer, and care of the dying patient.

scholarly journals Acute and Transitional Care or Rehabilitation? Retrospective analysis of discharge planning from a municipal hospital in Switzerland

2019 ◽  
Author(s):  
Lara Kollbrunner ◽  
Rost Michael ◽  
Koné Insa ◽  
Zimmermann Bettina ◽  
Padrutt Yvonne ◽  
...  
Keyword(s):  
Social Service ◽  
Transitional Care ◽  
Discharge Planning ◽  
Patient Discharge ◽  
Early Discharge ◽  
Negative Consequences ◽  
Municipal Hospital ◽  
Care Needs ◽  
Service Workers ◽  
Social Service Workers

Abstract Background Due to rising health care costs, in 2012 Switzerland introduced SwissDRG, a reimbursement system for hospitals based on lump sums per case. To circumvent possible negative consequences like reduction in length of stay, acute and transitional care (ATC) was anchored into the law (Federal act on health insurance) in 2011. ATC as a discharge option is applicable to patients with no capacity for rehabilitation, but are unable to return home and are in need of temporary professional nursing care. ATC is associated with higher out of pocket costs to the patient than rehabilitation. Since social service workers are responsible for organizing discharge of patients with ongoing care needs after hospitalization, the aim of this study was to investigate how social service workers manage patient discharge in light of the new discharge option ATC. Methods Data was collected from 660 medical records of inpatients from Zurich's municipal hospital, Triemli, in 2016. We compared patients discharged to ATC and rehabilitation using inferential statistics and qualitatively analyzed written statements from social service workers. Results Our results showed that patients discharged to rehabilitation had a higher total number of discussions, but a shorter duration of discussions. Patients discharged to rehabilitation faced more delays, above all because of unavailability of free places. Conflicts concerning discharge arose mainly because of costs, discharge placement and too early discharge. Conclusions Our findings demonstrate how important social service workers are in explaining to patients about different discharge options. The newness of SwissDRG and ATC is still likely to cause longer discussion times and, consequently, more workload for social service workers. Only a small fraction of patients disagreed with their place of discharge, mostly due to financial reasons.

Discharge planning for the patient with a new tracheostomy

1990 ◽  
Vol 10 (7) ◽  
pp. 73-79 ◽  
Author(s):  
EB Wilson ◽  
N Malley
Keyword(s):  
Critical Care ◽  
Planning Process ◽  
Discharge Planning ◽  
Signs And Symptoms ◽  
Critical Care Nurses ◽  
Care Plan ◽  
Discharge Care ◽  
Increased Risk ◽  
Hospital To Home ◽  
Discharge From Hospital

A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. To ensure a safe transition from the hospital to home, the patient and family must demonstrate competence in all aspects of tracheostomy care, must be able to recognize signs and symptoms that should be reported to the physician, and must have adequate support at home (such as homecare nurses, properly functioning equipment, and access to necessary supplies). These "musts" form the basis of the discharge care plan. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home. The information, encouragement, skills demonstrations, and referrals to other resources that critical care nurses provide help the patient adjust to a new tracheostomy.

Abstract 304: Characteristics of Acute Coronary Syndrome Patients Referred to the Bridge Transitional Care Clinic By Time to Readmission

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
George Cholack ◽  
Joshua Garfein ◽  
Rachel H Krallman ◽  
Delaney Feldeisen ◽  
Daniel G Montgomery ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Transitional Care ◽  
Discharge Planning ◽  
Post Discharge ◽  
Care Clinic ◽  
Icu Admission ◽  
Coronary Syndrome ◽  
Female Sex ◽  
Increased Risk ◽  
Early Readmission

Introduction: Prompt follow-up post-discharge is recommended by many readmission reduction initiatives. Identifying predictors of early readmission may inform discharge planning. We compared characteristics of acute coronary syndrome (ACS) patients (pts) based on time to readmission to determine factors associated with early readmission. Methods: Pts referred to the BRIDGE transitional care clinic following index admission for ACS from 2008-2017 were eligible. Demographics and inpatient clinical characteristics were compared between pts readmitted early (0-7 days post-discharge) versus late (8-30 days post-discharge). Multivariable logistic regression models were created to identify independent predictors of early readmission. Results: Of 1220 ACS pts, 198 were readmitted within 30 days; 70 (35.4%) were readmitted early, and 10.0% of these were readmitted for ACS. Early readmissions were more likely to be female, have an ED visit prior to readmission, and have an index ICU admission. Female sex [OR: 2.26, 95% CI: 1.23, 4.16] and ICU admission [OR: 2.20, 95% CI: 1.14, 4.24] were both independent predictors of early readmission. Conclusion: Female sex and ICU admission during index were associated with roughly twice the odds of early readmission. Non-white pts were also more often readmitted early (p=0.05), suggesting potential care disparities in this population. Future studies to identify pts at increased risk of early readmission and efforts to reduce disparities are warranted.

Transitional Care of Older Adults

2002 ◽  
Vol 20 (1) ◽  
pp. 127-147 ◽  
Author(s):  
MARY D. NAYLOR
Keyword(s):  
Older Adults ◽  
Decision Making ◽  
Health Care Providers ◽  
Planning Process ◽  
Transitional Care ◽  
Discharge Planning ◽  
Statistical Significance ◽  
Future Research ◽  
Care Providers ◽  
Care Needs

This chapter reviews 94 published research reports on transitional care of older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE, CINAHL, HealthSTAR, Sociological Abstracts and PsycINFO using combinations of the following search terms: transitional care, discharge planning, care coordination, case management, continuity of care, referrals, postdischarge follow-up, patient assessment, patient needs, interventions, and evaluation. Reports were included if published between 1985 and 2001, if conducted on samples age 55 and older, if relevant to nursing research, and if published in English. Intervention studies had to have a control or comparison group and a test for statistical significance. Four key findings from this review were identified. A high proportion of elders and their caregivers report substantial unmet transitional care needs, with the need for information and increased access to services consistently among the top priorities. Differences in expectations between and among patients, families, and health care providers, and the need for increased patient and family involvement in decision making, are common themes in discharge planning studies. Gaps in communication have been identified through the discharge planning process. Evidence about the effects of innovations in transitional care on quality and cost outcomes is sparse. Four main recommendations are made. Differences in older adults’ transitional care needs based on race, ethnicity, and educational level, with attention to potential disparities, require further study. Studies of strategies to promote effective involvement of patients and families in decision making throughout discharge planning are needed. The development and testing of referral and other information systems designed to promote the transfer of accurate and complete information across sites of care should be a research focus. A priority for future research should be continued study of strategies to improve transitional care outcomes of older adults and their caregivers.

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