Reducing Patient Wait Times Enhanced Discharge Education Program

Abstract

The problem is extended wait times among paediatric patients at the selected Paediatric Emergency Department (PED). This is a result of failure by nurses and clinicians to effectively educate patients at discharge, which causes many patients to return for complications listed in their discharge instructions. The extended wait times lead to patient dissatisfaction and poor organizational outcomes as patients may leave without care. Hospital readmission within 30 days of discharge remain a serious health concern in the US. Statistics indicate that 1 in five Medicaid patients return to hospital within 30 days of discharge. Cumulatively, readmissions alone account for approximately $42 billion in health spending annually. A literature review was conducted to gather evidence-based knowledge on strategies for enhancing the effectiveness of discharge procedures. Evidence was gathered by searching for US-based primary research articles in the JAMA Network, Cochrane Open Access, the Directory of Open Access Journals, and the Digital Commons Network published within the past five years. Systematic reviews and meta-analyses, as well as older articles, were excluded, but were kept as reference material and used in the narrative review. The evidence showed that effective pre-discharge education and post-discharge follow-up significantly reduced hospital revisits. Based on this evidence, the project seeks to reduce patient wait times at the PED by adopting an enhanced discharge education program that includes post-discharge follow-up phone calls. The project faces cost constraints given the large number of patients, time limitations, as it has to be completed within the given time frame, and the risk that staff may resist change.

Key words: discharge education, revisits, readmission

Background to the Problem

Every year, over 35 million discharges occur across the United States’ hospital network (Alper et al., 2022). The process of discharging a patient from hospital is complicated as it makes families and patients responsible for coordinating care. In an ideal transition of care, the healthcare provider prepares the patient by adequately communicating crucial discharge information on medication, side effects, and when to make follow-ups, guided by the patient’s health status and health literacy levels (Bajorek & McElroy, 2020). Studies have associated effective discharge education with greater medication compliance, and lower readmission and mortality risks (Boden-Alballa et al., 2018; dejong et al., 2020). For instance, dejong et al. (2020) found that a quality improvement bundle that included enhanced discharge information and follow-up reduced readmission rates in a pediatric hospital from 10 percent to 7.4 percent over a four-month period.

Unfortunately, healthcare providers may not always be in a position to predict a patient’s discharge day. So in most cases, discharges are done in an unstandardized and rushed manner on the day of discharge (Bajorek & McElroy, 2020). Patients mostly receive a bulk of new information that is explained in a rushed manner, with little consideration for health status and health literacy levels (Boden-Alballa et al., 2018). In most cases, healthcare providers use health-related jargon to explain medication side effects and indications, which patients may not understand or may find difficult to remember (Boden-Alballa et al., 2018). Emergency Department (ED) patients and caregivers will often receive discharge information across four domains: ED-based care, diagnosis and cause, instructions on when to return, and post-ED care (Boden-Alballa et al., 2018). In one study, researchers interviewed 140 English-speaking caretakers and patients upon release from the emergency department (ED) to assess how well they understood the discharge instructions they had received (Boden-Alballa et al., 2018). The study found that less than 15 percent of respondents had understood all four domains of ED discharge instructions (Boden-Alballa et al., 2018).

Unfortunately, poor understanding of discharge instructions is associated with unintended hospital revisits, a greater risk of readmission, and decreased patient satisfaction (Boden-Alballa et al., 2018). Statistics indicate that 1 in five Medicaid patients in the US return to hospital within 30 days of discharge. Cumulatively, readmissions alone account for approximately $42 billion in health spending annually.

Problem Statement

The main problem at the selected PED is extended wait times resulting from increases in the number of patients returning within two weeks of discharge. According to the nurse manager at the PED, over 65 percent of patients return within 14 days of discharge for complications listed in their discharge instructions or concerns expected in their diagnosis within the time frame of letting it run its course, such as fever. The primary reason is that providers and nurses are not taking the time to effectively use discharge tools and educate patients at discharge. The result has been declining patient dissatisfaction as shown by quarterly patient surveys. Patients have had to wait as long as four hours and the management is concerned that if the problem is not addressed, it could result in aggrieved patients leaving without care.

Resolution Strategy

Bajorek and McElroy (2020) identify certain risk factors that drive poor transitions and delivery of discharge education in healthcare settings. First, healthcare providers often rush the discharge process, overestimating the patient’s health literacy needs, social determinants, and readiness to learn (Bajorek & McElroy, 2020). Further, caregivers or family members may not be adequately involved in the discharge planning and education efforts (Bajorek & McElroy, 2020). As such, they may not understand the medication names, side effects, indications, diagnosis, and even the reasons or mechanisms for scheduling an appointment for their patient (Bajorek & McElroy, 2020). A third risk factor is that discharge instructions and education are often provided by different healthcare providers, who may use different health-related terms and wordings, causing confusion among patients (Bajorek & McElroy, 2020).

Strategies that address these factors could be categorized into post-discharge, pre-discharge, and bridging interventions (Alper et al., 2022). Post-discharge interventions include medication reconciliation, discharge planning, patient education, and scheduling of follow-up appointments (Alper et al., 2022). Common post-discharge interventions include home visits and regular follow-up phone calls; while bridging interventions include clinician continuity between outpatient and inpatient settings and use of transition coaches (Alper et al., 2022).

The purpose of the proposed project is to reduce the number of reoccurring visits resulting from ineffective discharge instructions by 50% over the next six months through implementing a program that incorporates enhanced pre-discharge education and post-discharge follow-up phone calls. The projected goal is to reduce patient wait times to less than one hour, thus reducing the number of patients who leave without care, and ultimately increasing patient satisfaction.

The project uses the IOWA model of Evidence-Based Practice to promote the proposed intervention. The IOWA model was selected for two reasons. First, it effectively guides and supports healthcare professionals at the PED to: identify lack of proper patient education on discharge as a source of reoccurring visits that leads to extended wait times; select adequate pre and post-discharge evidence-based interventions; implement the interventions; evaluate the interventions; and finally integrate the interventions in their daily practice (Cullen et al., 2022). Further, the IOWA model has a stage of evidence appraisal, which ensures that healthcare providers use the best available evidence for clinical decision-making (Cullen et al., 2022).

Using the IOWA model, the project will implement an enhanced discharge education program that will involve giving patients a workbook and videos emphasizing the four domains of ED discharge instructions: ED-based care, diagnosis and cause, instructions on when to return, and post-ED care. The videos will educate patients on three crucial skills: physician-patient communication, medication adherence, and risk reduction. Additionally, the providers will make follow-up calls to patients 72 hours, 2 weeks, 1 month, and 3 months after discharge to assess their progress. Both interventions are adapted from the study by Boden-Alballa et al. (2018), and were found to be effective in reducing the risk of vascular risk among patients discharged from the ED.

Literature Review

Researchers have conducted several studies to assess the effectiveness of pre-discharge, post-discharge, and bridging discharge interventions in reducing the risk of reoccurring patient visits as a result of poor discharge education. In one such study, Boden-Alballa et al. (2018) conducted a randomized controlled trial to test the efficacy of a discharge program that combined enhanced discharge education strategies facilitated by a community health nurse, and post-discharge follow up phone calls in reducing vascular risk among patients with stroke and ischemic attacks. The sampled 1,089 patients visiting four New York-based facilities were randomized into the control or treatment groups. The control group received the usual discharge care, while the treatment group received a video and workbook emphasizing three skills: physician-patient communication, medication adherence, and risk reduction, in addition to post-discharge follow up phone calls. The results showed clinically significant differences in blood pressure reduction between the treatment and control groups. The evidence showed that that enhanced discharge education and follow-up phone calls significantly reduced vascular risk upon discharge.

In a similar study, deJong et al. (2020) conducted a quality improvement longitudinal study to assess the efficacy of enhanced discharge education and post-discharge follow up in reducing 30-day readmission rates among pediatric patients. A comparison of pre and post-intervention readmission rates found a reduction of 2.6%, from 10.3% prior to implementation to 7.4% after implementation. The study concluded that pre-discharge planning and education, combined with post-discharge follow up and access to a transition clinic, significantly reduced readmission rates among pediatric patients.

Other studies have focused on specific discharge education strategies. For instance, Hodges et al. (2021) conducted a prospective non-randomized controlled trial to test the effectiveness of the teach-back method of delivering discharge education. The teach-back method involves asking the patients to explain in their own words crucial information about their health. Adopting a longitudinal design, the study found that 61% of patients were satisfied when the provider used the teach-back method to deliver discharge information, as compared to a 59% when normal education techniques were used (Hodges et al., 2021). As such, the researchers concluded that the teach-back method may improve patient satisfaction when used in delivery of discharge education.

Other studies have focused on post-discharge strategies only. For instance, Fruhan and Bills (2022) implemented a call-back program that involved making follow-up calls to patients upon discharge after discharge from the ED. 8,810 participants were randomized into the control and treatment groups, with the control group receiving only standard care. Odds ratio analysis showed that the odds of revisits and readmission were significantly lower for the intervention group as they were more likely to understand their discharge plan, obtain medication, and make successful follow-up plans with healthcare providers.

There is sufficient evidence to support the use of both pre and post-discharge interventions. The proposed project thus combines the use of enhanced discharge education and follow-up call back interventions to test their efficacy in reducing reoccurring visits due to lack of proper information upon discharge.

Project Evaluation

Several evaluation strategies will be deployed to evaluate the success of the proposed project. It would be prudent to note that as Rortveit, Hansen, Joa, Lode, and Severinsson (2020) point out, “the choice of evaluation method must be determined by its appropriateness for the purpose and intended use” (21). In the present scenario, an impact evaluation would be conducted to gather relevant information about the ‘impact’ or observed changes that could be attributed to the strategy implemented. The targeted impact of the project is to improve patient satisfaction. To evaluate the project’s impact, patient satisfaction levels for sampled patients will be measured at baseline and several months into the project’s implementation using the short form of the Patient Satisfaction Survey. Pre-intervention and post-intervention mean scores will be compared using analysis of variance (ANOVA) to check whether significant differences exist in the two data sets.

It would also be beneficial to consider the relevance, effectiveness as well as sustainability of the said strategy. When it comes to its effectiveness, there would be need to determine whether the objectives of the strategy were achieved. More specifically an evaluation targeting efficacy would assess the extent of the reduction in hospital revisit rates within 30 days of discharge and the change in patient wait times following the implementation of the project. This would involve randomly selecting records of a sample of patients and then comparing hospital revisit rates before the implementation of the discharge program and after its implementation (Boden-Alballa, et al., 2018). A similar strategy would be adopted to assess the change in wait times. Average wait times will be obtained at baseline and a few weeks into the project’s implementation by comparing how long patients take between triage and when they are called into the consultation room. The two data sets will then be compared using analysis of variance (ANOVA) tests to determine whether the differences in wait times are clinically significant. In as far as relevance is concerned, the study will establish the extent to which the strategy’s objectives align with the overall objectives and mission of the organization. Further, there would be need to also establish whether any benefits derived, i.e. in relation to reduced wait times in the Pediatric Emergency Department, are continual, i.e. after taking into consideration the available resources.

The project will adopt a number of dissemination strategies in sharing the findings with other stakeholders. The audience in this case happens to be an internal audience. Conference presentations would be the best way to share successes and failures with this particular audience. This approach is beneficial because it is more proactive than other dissemination methods such as the utilization of brochures or flyers. As Powell et al. (2019) observe, a proactive approach comes in handy in the promotion of stakeholder engagement.

Evidence –Based Practice Model: The IOWA Model

The IOWA model is a five-step structural framework that serves as a guide for healthcare professionals on how to use research findings to support the delivery of quality care to patients (Cullen et al., 2022). The IOWA model contains the following key steps:

Identification of the Clinical Problem

This involves critically reviewing processes and available data to identify gaps requiring improvement. In this step, the project team held a meeting with the nurse leader at the PED, which revealed that 65% of patients were returning to the hospital within 1 month of discharge for failing to understand instructions given during discharge. As such, it would be beneficial to identify evidence-based interventions that could help solve the problem.

Selection of Research Evidence

The second step in the IOWA model involved searching for available evidence on possible strategies, appraising the evidence, and selecting the most appropriate evidence for extending quality care to patients (Cullen et al., 2022). At this stage, six full articles were analyzed, from which four primary research articles (levels IV to VII of evidence) were ruled feasible in guiding practice. Most of the available evidence focuses on pre-discharge education and post-discharge follow-up calls, and hence, these were selected as the most plausible interventions for the proposed project.

Applying Evidence in Practice

In the third step of the IOWA model, the team applies the selected interventions in practice. The first step involved setting objectives (purpose) and determining the overall project goal. Thereafter, the healthcare providers will be trained on how to offer enhanced discharge education by considering a patient’s culture, literacy levels, and health needs. The session will also focus on sharing knowledge around the identified problem, the implementation plan, IOWA model, the selected evidence-based interventions, and the targeted outcomes. The healthcare providers will then use the guide they receive during the training to prepare patients for discharge