PROMOTING FAMILY DISCHARGE READINESS THROUGH AN IMPROVED DISCHARGE TRANSITION PROCESS: A QUALITY IMPROVEMENT PROJECT

Stephanie Fingland, BSN, RN, CPN, DNP student University of Missouri- Sinclair School of Nursing

Background •  The quality of hospital-to-home discharge transitions is a critical issue

affecting the United States health system. More than 20% of parents report problems in the transition of care from hospital to home (Auger et al., 2014).

• Discharge planning is mandated by federal legislature and includes strategies such as: assessment of barriers to discharge, making decisions regarding post hospitalization care, engagement of family in communication, provision of supplies for home care, and completing procedures such as scheduling follow-up appointments (Goncalves-Bradley et al., 2016).

• Discharge readiness is the ability to understand and execute the intended discharge care plan, and is more likely when parents believe their child is healthy enough to leave the hospital, and that they understand how to manage their child’s health needs (Berry et al., 2014).

•  Total estimated annual costs of 30-day preventable readmission rates for pediatric hospitals are $533 million, or 27.3% of all-cause readmission costs, thus accounting for 4.6% of the total costs for all pediatric hospitalizations (Gay et al., 2015).

INTRODUCTION

Project Intervention

1-Month Survey (n = 38)

2-Month Survey (n = 53)

. Demographics • Age: Mean age of 8.23 years (SD = 1.2) for time point 1 and 8.92 years (SD = 0.70) for the time point 2 group which was not statistically significant between groups, t(89) = -.56, p = .58, 95% CI [-3.16, 1.78]. • Length of Stay (LOS): There was a decrease in mean length of stay of 5.5 days (SD = 12.2) from time point 1 to 2.3 days for time point 2 (SD = 2) but was not statistically significant, t(38.42) = .12, p = .12, 95% CI [-.86, 7.25], d = .4. • Specialty Service: General Surgery (47%, n = 38), followed by ENT (17.5%, n = 14), Orthopedics (10%, n = 8), and EMU/Neurology (7.5%, n = 6). There was no statistically significant difference between services in the two groups, χ2 (8) = 7.32, p = .50

MATERIALS AND METHODS

①  Objective 1- 10% increase in family perception of readiness for discharge •  Met: 100% of parents had overall readiness at time of discharge for both time

points. ①  Objective 2- 10% increase in documentation of review of the discharge plan •  Not met: The stakeholders decided not to evaluate this measure after project

implementation. •  Including parents in the discharge planning process significantly improves their

ability to cope with the stress of taking their child home from the hospital, as well as their confidence in managing their child’s needs once they return home. • The implementation of an education program to improve parental discharge

readiness contributes to closing the knowledge gap in family discharge readiness.

For questions, please contact: sms6h2@mail.missouri.edu Sinclair SON URL http://nursing.missouri.edu/index.php

• Overall Readiness: •  Parents in both time points 1 (100%, n = 37) and 2 (100%, n = 53) indicated

that overall, they personally felt ready to take their child home. •  There was no statistically significant difference found in overall readiness

between the two groups, χ2 (1) = .71, p = .40. • Individual Item Significance: Of the 24 items included in the RHDS scale, two items were statistically significant, and both had moderate clinical significance:

• Lower stress at time of discharge: t(87) = -1.97, p = .05, 95% CI [-2.35, .01], d = .6 • Confidence in ability to cope with demands at home: t(88) = -2.00, p = .05, 95% CI [-.85, .00], d = .6.

• Subscales: There was no statistically significant difference in all 5 subscales. There was small clinical significance in increased parent personal status, knowledge, coping, and expected support.

RHDS SURVEY RESULTS

CONCLUSIONS

REFERENCES

RESULTS

ACKNOWLEDGEMENTS

“Preparing to Go

Home” Discharge handout

Daily Review of Discharge Plan and

Needs

Improved Parental

Perception of Discharge

Readiness Design: •  Quality improvement project with data collection of survey results

at 1 month and 2 months post-implementation. Intervention: •  On admission, a discharge-planning tool was given to parents by

the bedside RN. •  Interdisciplinary team performed daily rounding with the bedside

RN to review the plan for discharge and any concerns the family may have.

Tools: •  Readiness for Hospital Discharge Scale-Parent version (RHDS):

29-item instrument parent-report summated rating scale with 11-point scaling format, α > .90, calculated on individual subscales: parent personal status, child personal status, knowledge, coping, and expected support (Weiss et al., 2008).

Measures: •  Descriptive statistics provide an overview of the project sample. •  Nominal level data: Chi-square Test of Independence •  Ratio level data: Independent t-test •  Clinical significance: Cohen’s d coefficient with .2, .5 .8

corresponding with small, medium, and large respectively. •  IBM SPSS Statistics version 23 (Chicago, IL) was used for

statistical analysis. Statistical significance is defined as p < .05.

Setting and Participants: •  72-bed post-operative surgical unit of a private, not-

for-profit 486-bed pediatric urban academic hospital providing care to a seven state region.

•  Target population - purposive, convenience sample of parents or caregivers of pediatric patients admitted to the surgical unit of the hospital.

0 5 10 15 20 25

General Surgery

ENT

Neurosurgery

Rehab

Orthopedics

EMU

Urology

Medical

Plastics

2-Month 1-Month

0

1

2

3

4

5

6

7

8

9

10

Age LOS

1-Month 2-Month

PICOT QUESTION & OBJECTIVES

The project director would like to thank her doctoral committee chair, Dr. Jan Sherman, PhD, RN, NNP-BC; members: Dr. Urmeka Jefferson, PhD, RNC-LRN; Debra Quackenbush, MS, RN, CPS; the nursing staff of Children’s Hospital Colorado’s SMSC department for their time and insight; and the Sinclair School of Nursing for helping make this project a reality.

PICOT Question • In pediatric patients (P), how does a family-centered discharge transition planning process (I), compared to the usual discharge process (C), affect family readiness for discharge (O) within two months of implementation? Objectives ①  There will be a 10% increase in family perception of readiness for discharge

based on the Parent Form of the Readiness for Hospital Discharge Scale (RHDS).

②  There will be a 10% increase in documentation of daily review of the discharge plan with family.

1.  Auger, K., Kenyon, C., Feudtner, C., & Davis, M. (2014). Pediatric hospital discharge interventions to reduce subsequent utilization: A systematic review. Journal of Hospital Medicine, 9(4), 251-260. doi:10.1002/jhm.2134

2.  Berry, J., Blaine, K., Rogers, J., Mcbride, S., Schor, E., Birmingham, J., . . . & Feudtner, C. (2014). A framework of pediatric hospital discharge care informed by legislation, research, and practice. JAMA Pediatrics, 168(10), 955. doi:10.1001/jamapediatrics.2014.891

3.  Gay, J., Agrawal, R., Auger, K., Beccaro, M., Eghtesady, P., Fieldston, E., . . . & Shah, S. (2015). Rates and impact of potentially preventable readmissions at children's hospitals. Journal of Pediatrics, 166(3). doi:10.1016/j.jpeds.2014.10.05

4.  Gonçalves-Bradley, D., Lannin, N., Clemson, L., Cameron, I., & Shepperd, S. (2016). Discharge planning from hospital. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd000313.pub5

5.  Weiss, M., Johnson, N. L., Malin, S., Jerofke, T., Lang, C., & Sherburne, E. (2008). Readiness for discharge in parents of hospitalized children. Journal of Pediatric Nursing, 23(4), 282-295. doi:10.1016/j.pedn.2007.10.005

Subscale Timepoint 1 (n = 38)

Timepoint 2 (n = 53)

p value Cohen’s d

Parent Personal Status

60.97 (SD = 6.67) 62.13 (SD = 7.48) .47 .2*

Child Personal Status

39.32 (SD = 9.07) 38.46 (SD = 7.31) .62 .1

Knowledge 83.08 (SD = 8.96) 103.42 (SD = 139.82) .37 .2*

Coping 28.26 (SD = 2.06) 28.96 (SD = 1.7) .08 .4*

Expected Support

31.03 (SD = 9.97) 34.52 (SD = 10.04) .11 .4*

Sample Size Calculation: •  Using a confidence interval of 95%, a maximum of

7.5% margin of error, a population size of 200, with a 25% survey response distribution, a minimum of 120 surveys for each time points (Raosoft, n.d.).

•  120 surveys not available at time point 1 (n = 38) or time point 2 (n = 53), all 91 available surveys were utilized.

“PREPARING TO GO HOME” TOOL