Comprehensive Discharge Education: A Case Study

Improving Individual Health Practices and Patient Understanding through Comprehensive Discharge Education

Improving Individual Health Practices and Patient Understanding through Comprehensive Discharge Education.
As healthcare enters a new frontier with the implementation of the Affordable Care Act (ACA), millions of previously uninsured Americans will flood the healthcare market. As members of this complex and vast healthcare system, individuals will constantly transition on a health and wellness continuum as well as into and out of acute care, community care, home health care, and self care. In our current state, a frequently encountered problem in hospitals is
the integral but ill-defined role of the staff nurse in planning for patient discharge. (Maramba et al., 2004). In order to empower patients to become stewards of their own health; a process to provide comprehensive discharge education needs to be implemented when patients transition away from acute care. Prior to initiating this process in regards to patients, nurses themselves must be satisfied with the discharge process and deem it effective. Ensuring that patients’ informational needs have been met prior to hospital discharge sets the stage for successful self-management of recovery at home. (Maloney et al., 2008). This can only be accomplished if nurses place stock in this very vital process first.
Clinical Problem Conscientious discharge planning has been associated with positive outcomes including higher patient satisfaction, improved referral and utilization of post-discharge services, and fewer readmissions.
(Maramba et al., 2004). However, current trends in healthcare indicate higher acuity patients in hospitals for shorter amounts of time and being released to home or community care sooner than ever before. Inadequate discharge planning is contributing to readmissions, inadequate follow up after discharge and lack of preparation for self-care after discharge because of insufficient patient education. (Maramba et al., 2004). Jack (2009), found that patients who have a clear understanding of their after-hospital care instructions are 30% less likely to be readmitted or visit the emergency department. Interceding to thwart preventable readmissions will aide to ease the stress on an already overburdened healthcare system as well as to reduce and save health care expenditures. Maloney found that “patients discharged with unmet needs are at a higher risk for posthospital complications, readmissions, and decreased satisfaction with care.” (Maloney et al.,
1998). The study conducted by Maramba, Richards, and Larrabee pinpointed two reasons of how shorter hospital stays are affecting patient education. First, shorter hospital stays limit the amount of time that nurses can spend with their patients assessing their needs and educating patients about self-care. Second, shorter stays affect patients’ readiness to learn. (Maramba et al., 2004). Patients are bombarded with tests, paperwork, and information in a setting with constant commotion and unfamiliar noises that is less than ideal for learning. An exploratory study by McKenna, Keeney, Glenn, and Gordon indicated that communication problems between patients, doctors, and nurses led to patients and their families receiving insufficient information about discharge and inadequate instructions following discharge. (McKenna et al., 1999). Insufficient and inadequate discharge information is merely setting patients up to fail once discharged and leaving them no other option except to return to the same healthcare system that failed them in the first place. This problem can lead to serious complications in many chronic illnesses. Other alarming trends have been identified in post discharge care that point toward a fragmented discharge process. These trends include: patients’ forgetting to pick up prescriptions, delay or failure to follow up in regards to home health care, lack of understanding of the discharge instructions, and a failure to obtain follow up appointments after discharge. (Eggenberger et al., 3013). A study conducted by McBride (1995) showed that 70% of interviewed patients reported they were not given any advice about self-care at home. In addition, the study conducted by McKenna et al., 24.1% of nurse respondents, (a quarter of all respondents) stated that there should be uniform discharge documentation. (McKenna et al., 1999). Lack of a comprehensive discharge process affects every aspect of the healthcare team; patients, nurses, physicians, caregivers, home health care, community clinics, hospitals and insurance companies. In addition the financial cost it imposes on the struggling healthcare system cannot be ignored. Prior to tackling some of the larger issues previously mentioned here, examining the lack of a uniform process and discharge protocol is the first step in aiding patients to prevent post-discharge complications. Streamlining the discharge process can help patients and families to better understand their discharge instructions, their medications, after-discharge care and possible complications while at the same time avoiding preventable hospital readmissions, preventable complications, and increasing patient satisfaction.
Evidence of a Problem In the past twelve months many headline worthy changes have been made in regards to documentation practices. At St. Joseph’s Medical Center (SJMC) the implementation of an electronic health record as of November 2012 has created some unforeseen problems in nursing workflow. A discharge process vague from the beginning has now become even more ill-defined. A quantitative measurement of effectiveness of, as well as nursing satisfaction with, the discharge process will reveal that a large majority of nurses at SJMC 2West/3North are unsatisfied with the current discharge process, the lack of education on the discharge process, and the lack of a uniform discharge policy.
Goal of Quality Improvement Project The goal of this improvement process is to primarily streamline the discharge process and secondarily increase nursing satisfaction with the discharge process, access to the discharge policy, and knowledge of a discharge protocol. Exploring barriers to smooth, problem-free discharges from a nursing perspective will eliminate or minimize these barriers. The development of an explicit, accessible discharge policy will help nurses to expedite the discharge process with an end result of increased patient satisfaction, decreased complications in post-acute care discharges, and decrease readmissions.
Key Factors In order to create a successful quality improvement project frontline nursing staff needs to be included in every step from the beginning. Acquiring nursing staff involvement from the start ensures the acceptance and support for an effective change. Participation from nursing staff will be garnered before, during, and after implementing this quality improvement plan. Important stakeholders in this process include: frontline staff RN’s, unit clerks, first line RN supervisors, 2west/3north department manager, and quality improvement director. Every one of these entities will to be included in all aspects of implementing this change. All personnel involved in the creation, implementation of, and monitoring of this change must be aware of and support the change ideals, namely: creating a uniform accessible discharge policy to all staff. Barriers to a successful implementation of the change process includes staff nurses who may fear or oppose a change in current practice as well as nurses who may possess an unfounded fear of a presumed increase in workload. Education of frontline staff and the involvement of nursing staff in the process change can help to eliminate opposition and misconceptions regarding a change in current workflow. Empowering staff to be involved in policy change and creation of a streamlined process can help to garner support and staff buy-in. Recruiting the support of informal leaders on these specific department settings can help to motivate other staff nurses to support the change.
Conclusion
As more consumers enter the healthcare system, having a uniform easily accessible discharge process will expedite the patient discharges, increase nursing and patient satisfaction, decrease post-discharge complications, increase patient discharge education practices, ensure timely follow up care, and availability of discharge medications.
At the conclusion of this quality improvement it is anticipated that SJMC 2west/3north will have developed and implemented a discharge policy that can then be introduced hospital wide. Expediting patient discharges in a safe, timely, yet effective manner without increasing nursing workload or documentation will assist to free up bed availability and ensure a smooth transition from acute care to
home.

References
Eggenberger, T., Garrison, H., Hilton, N., Giovengo, K. (2013). Discharge phone calls: using person-centered communication to improve outcomes. Journal of Nursing Management, 21, 733-739. Doi: 10.1111/jonm.12100.
Jack, B. (2009). Study shows readmissions drop when patients understand discharge instructions. Hospital Case Management.
Maloney, L., Weiss, M. (2008). Patient’s perceptions of hospital discharge informational content. Clinical Nursing Research, 17 (3), 200-219. Doi:
10.1177/1054773808320406.
Maramba, P., Richards, S., Larrabee, J. (2004). Discharge planning process: applying a model for evidence-based practice. Journal of Nursing Care Quality, 19 (2), 123-
129.
McKenna, H., Keeney, S., Glenn, A., Gordon, P. (2000). Discharge planning: an exploratory study. Journal of Clinical Nursing.9, 594-601.