coursework-banner

Discussion: Agenda Setting

NURS 8100 Discussion: Agenda Setting

Discussion: Agenda Setting

Clinical Practice Issue: Frequent Admissions due to Poor Discharge Nursing Education. Reducing hospital readmissions is a national focus for healthcare reform. Consequently, patient discharge education is increasingly important for improving clinical outcomes and reducing hospital costs (Polster, 2015). According to the Centers for Medicare and Medicaid Services (CMS), nearly 20% of all Medicare patients are readmitted to the hospital within 30 days of discharge; 34% are readmitted within 90 days of discharge (Polster, 2015)

The quality of discharge teaching is statistically linked to decreased readmission rates. Nursing most often bears the major responsibility of patient and caregiver teaching (Luther, et al., 2019). Currently, discharge teaching is complicated by problems including time constraints, patient and caregiver overload, and coexisting comorbidities that add complexity to the patient’s care needs at home. (Luther, et al., 2019). A structured discharge process with tools to help healthcare organizations improve their discharge process to decrease readmission rates need to be considered (Luther, et al., 2019).

The CMS expects nurses and other healthcare team members to address modifiable factors that can increase the chance of rehospitalization, such as (1) unplanned and early discharge or insufficient post-discharge support, (2) inadequate follow-up, (3) therapeutic mistakes, (4) adverse drug events, and (5) failed handoffs (Polster, 2015). The policy of interest will focus on failed handoffs or poor discharge education. Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organizational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues (Hesselink, et al., 2015)

What strategies would you use to inform stakeholders and persuade them of the importance of your identified clinical practice issue?

There are several strategies that can be used to inform stakeholders while persuading them on the importance of a new policy (Hydera, et al., 2010). For example, the policy of interest must be established and stakeholders to be included.  The stakeholders will entail

Discussion Agenda Setting
Discussion Agenda Setting

clinical nursing, physicians, patient experiences, pharmacy, quality and safety, nursing managers and directors. Once a policy of interest and stakeholders have been established, accepting of the stakeholder’s perspective on the issue would be first taken into consideration. Expectations related to interventions can predict the likelihood of successful intervention implementation through intervention refinement and incorporation of innovative ideas, sharing perspectives with key stakeholders will enhance solidarity around interventions for improving discharge education and reduction of frequent admits (Hydera, et al., 2010). Stakeholder engagement throughout research generation and policymaking becomes critical to strengthening the research–policy interface.

Fostering such linkages between mediators, individuals or institutions with different stakeholders will encourage strong research-policy linkages (Hydera, et al., 2010). Another strategy that can be used to persuade stakeholders on the importance of improving discharge education to decrease frequent admissions is to use policy briefing, a new approach to packaging research evidence for policymakers (Lavis, et al., 2009). The first step in a policy brief is to prioritize a policy issue, followed by use of systematic reviews to mobilize full range research evidence to the various features of the issue.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Discussion: Agenda Setting

Hesselink, G., Zegers, M., MyVernooij-Dassen, M., Barach, P., Kalkman, C., Flink, M., Ön, G., Olsson, M., Bergenbrant, S., Orrego, C., Suñol, R., Toccafondi, G., Venneri, F., Dudzik-Urbaniak, E., Kutryba, B., Schoonhoven, L., & Wollersheim, H. (2014). Improving patient discharge and reducing hospital readmissions by using Intervention Mapping. BMC Health Services Research. 14: 389.

Hydera, A., Syeda, S., Puvanachandraa, P., Bloomb, G., Sundarama, S., Mahmoodc, S., Iqbalc, M., Hongwend, A., Ravichandrane, N., Oladepof, O., Pariyog, D., & Petersa, D. (2010). Stakeholder analysis for health research: Case studies from low- and middle-income countries. Public Health, 124(3): 159-166

Lavis, J. N., Permanand, G., Oxman, A. D., Lewin, S., & Fretheim, A. (2009). SUPPORT Tools for evidence-informed health Policymaking (STP) 13: Preparing and using policy briefs to support evidence-informed policymaking. Health Research Policy & Systems, 71–79.

Luther, B., Wilson, R. D., Kranz, C., & Krahulec, M. (2019). Discharge processes: what evidence tells us I most effective. Review Orthopedic Nurse; 38(5): 328-333.

Polster, D. (2015). Preventing readmissions with discharge education. Nursing Management, 46(10):  30-37.

Hello D….,

This is an outstanding post on the issue of frequent admissions due to poor discharge nursing education. Minimization of hospital readmission is currently a national focus for the health care system. Many hospital readmissions are preventable and emanate directly from uncoordinated care. As such, patient discharge education is essential in enhancing clinical outcomes and lowering hospital costs (Oh et al., 2021). Patient education during discharge matters because the current discharge process is intricate, inefficient, and time-consuming (Gülşen & Akansel, 2020). Patients are often overwhelmed and rushed at discharge. The discharge information they are given through verbal instructions or a pile of aftercare guidelines they are handed on discharge are often infective. Ideally, the weakest link to hospital readmissions entails discharge procedures including inadequate post-discharge support, failed handoffs, premature discharge, and poor follow-up (Sharma & Rani, 2020). Therefore, proper education of patients both after discharge and at home and providing them with the appropriate tools they deserve to care for themselves or their families is essential in a significant reduction of the readmission rates in hospitals.

References

Gülşen, M., & Akansel, N. (2020). Effects of discharge education and telephone follow-up on cataract Patients’ activities according to the model of living. Journal of perianesthesia nursing35(1), 67-74. https://doi.org/10.1016/j.jopan.2019.04.010

Oh, E. G., Lee, H. J., Yang, Y. L., & Kim, Y. M. (2021). Effectiveness of discharge education with the teach-back method on 30-day readmission: a systematic review. Journal of patient safety17(4), 305-310. doi: 10.1097/PTS.0000000000000596

Sharma, S. K., & Rani, R. (2020). Nurse-to-patient ratio and nurse staffing norms for hospitals in India: a critical analysis of national benchmarks. Journal of family medicine and primary care9(6), 2631. Doi: 10.4103/jfmpc.jfmpc_248_20

Thank you for your post this week.

Hospital readmissions are a serious and costly issue and I appreciate your comprehensive capture of how to inform stakeholders and promote collaboration to prevent them. Your multidisciplinary approach will be beneficial in your attempt to get others to believe in the initiative. You make a good point about the initial prevention of hospital readmissions through teaching and patient education. In an article by Mashadi et al (2021), the investigators conducted a literature review to determine the best educational format to prevent readmissions. The authors found that teach-back education where you have the patient demonstrate a treatment they will need to administer or have the patient verbally educate the nurse in return, and Mhealth were the most effective strategies. The Mhealth approach provided real-time answers to questions through a telehealth platform. Patients reported the ease of access to a provider who could access questions quickly certainly contributed to the prevention of readmission. Habibzedeh et al. (2021), go on to emphasize that the in-person time spent at discharge to teach and investigate any gaps in knowledge goes a long way to prevent readmissions.

References:

Habibzadeh, H., Bagherzadi, A., Didarloo, A., & Khalkhali, H. (2021). The effect of patient education based on health belief model on hospital readmission preventive behaviors and readmission rate in patients with a primary diagnosis of acute coronary syndrome: a quasi-experimental study. BMC Cardiovascular Disorders21(1), 595. https://doi.org/10.1186/s12872-021-02413-8

Mashhadi, S. F., Hisam, A., Sikander, S., Rathore, M. A., Rifaq, F., Khan, S. A., & Hafeez, A. (2021). Post Discharge mHealth and Teach-Back Communication Effectiveness on Hospital Readmissions: A Systematic Review. International Journal of Environmental Research and Public Health18(19). https://doi.org/10.3390/ijerph181910442

As the chair of the Nurse Peer Review Council at my institution, we review many problems that arise from clinical practice issues that are unresolved. In the first two months of 2022, we have reviewed clinical practice issues with the nurse-to-nurse handoff, staffing shortages, and failures to escalate the chain of command.

I have been a perinatal services director for over 10 years and in my time as a leader, I have often felt that the patient ratios in the perinatal services arena are not in alignment with the Association of Women’s Health and Neonatal Nursing (AWHONN) staffing acuity guidelines. Although these guidelines were created in 2010 to promote caring for patients in the perinatal period in a safe manner based on the acuity of the patient (Simpson et al., 2019) hospital financial colleagues do not understand the importance, and frequently these guidelines have to be overlooked to maintain compliance financially. The guidelines break down different types of diagnosis and acuity of specific clinical care scenarios and rank them into categories. This information is further broken down into the number of FTEs that would be appropriate to care for this type of patient. An example would be that any patient that is pushing while in labor would require a 1:1 patient ratio whereas three patients in triage could be cared for by one nurse. The problem with this is that patients can move in and out of different levels of acuity based on their course of labor up to and after delivery. From a financial and productivity perspective this does not make sense. Staffing for a patient that begins at the lowest level of acuity then turns into the highest level of acuity, and then back to a moderate level of acuity after delivery is hard to measure from a productivity standpoint. This is even harder to maintain if departments are held to a productivity standard that is not in alignment with the patient ratios that mirror actual care a patient needs to receive during their hospital stay. The result is less safe care for patients, poor outcomes for mothers and infants, and staff dissatisfaction and burnout (Simpson, 2016).

I am currently working with an internal PI specialist piloting a program for the health care system that involves assessing the AWHONN staffing acuity guidelines and how often my labor and delivery unit is overstaffed or understaffed based on the AWHONN staffing acuity guidelines. We have collected eight months of data and have now created a presentation for the senior leadership team to help inform them of the need to deploy additional resources at a certain time of the day and on certain days of the week. This additional resource would increase the safety of care being provided to mothers and infants.

Some of the strategies I have used up to this point are in an agency for healthcare and research quality toolkit (AHRQ). The strategies include having a well-outlined plan that involves getting the right people on the team for the project, identifying a champion, communicating regularly with the stakeholders, and moving systematically through the stages of a project (www.ahrq.gov). By doing this the end-user has a well-developed objective presentation to support the need for a change. The importance of presenting a proposal that not only includes the need for change based on safety, but needs to include the financial, and operational impacts also.

References:

Agency for Healthcare Research and Quality. (October, 2014). Designing and Implementing Medicaid Disease and Care Management Programs. Retrieved from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm2.html

 

Simpson, K. R., Lyndon, A., Spetz, J., Gay, C. L., & Landstrom, G. L. (2019). Incorporation of the AWHONN Nurse Staffing Guidelines into Clinical Practice. Nurse Women’s Health, 23(3), 217–233. https://doi.org/10.1016/j.nwh.2019.03.003

 

Simpson, K. R., Lyndon, A., & Ruhl, C. (2016). Consequences of inadequate staffing include missed care, potential failure to rescue, and job stress and dissatisfaction. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 481–490. https://doi.org/10.1016/j.jogn.2016.02.011