Systematic Review and Review

¶ … EBP is to facilitate strategy to eradicate short cycle return to second readmission of psychiatric patients on hospital beds. Doing so will assist health care providers in addressing the issue of bed shortage. Reduction of readmission rates allows more space to be available for other patients and helps to cut costs as well as bring about better conformity with governmental regulations.

Search Process

The search process used in this literature review began with searching key words in online databases such as Cochran Review, CINAHL, and other nursing research journal databases. Google Scholar was used as the primary search engine, with filters set to permit results from these particular databases. Key words used included "reducing readmission rates," "readmission psych," "causes of readmission psych hospital," "psych hospital readmission," "reduction of psych readmission," and other combinations of key words identified by relevant articles found after conducting these searches. More than a thousand articles were yielded in the various searches. These number were trimmed according to relevance and to year produced, with only the most recent studies being chosen for the final selection. Common key words among relevant articles were also used to conduct more searches until a collection of a 15 articles were gathered. The hierarchy of evidence was then used to select the strongest studies, including a systematic review and a randomized-control trial. Articles that were not selected included case editorials and studies where no clear conclusion was obtained by the researchers.

Critical Appraisal

The critical appraisal process utilized for this literature review included identifying the results of the studies, assessing the validity of the studies, determining whether the results of the studies would facilitate patient care, recognizing similarities between the subjects of the study and the patients who are the focus of this EBP, and whether the study was qualitative or quantitative in nature. Studies selected for this review were then ranked according to strength in terms of the hierarchy of evidence, with systematic reviews and meta-analyses ranking as the strongest at Level 1, randomized-controlled trials next at Level 2, and case reports last at Level 7.

The studies selected for this review were:

Burns, T., Rugkasa, J., Molodynski, A. et al. (2013). Community treatment orders for patients with psychosis (OCTET): A randomized controlled trial. The Lancet, 381(9878): 1627-1633. DOI: http://dx.doi.org/10.1016/S0140-6736(13)60107-5.

This study is randomized controlled trial of the second highest level of strength (with definitive results) according to the hierarchy of evidence (Level 2).

Kalseth, J., Lassemo, E., Wahlbeck, K., Haaramo, P., Magnussen, J. (2016). Psychiatric

readmissions and their association with environmental and health system characteristics: a systematic review of the literature. BMC Psychiatry, 16: 376. DOI: 10.1186/s12888-016-1099-8.

This study was a systematic review and thus of the highest level of evidence at Level 1.

Kripalani, S., Theobald, C., Anctil, B., Vasilevskis, E. (2013). Reducing hospital readmission: Current strategies and future directions. Annual Review of Medicine, 65: 471-485. DOI: 10.1146/annurev-med-022613-090415

This study is another systematic review and thus at the highest level (1) of hierarchy of evidence.

Tulloch, A., David, A., Thornicroft, G. (2016). Exploring the predictors of early readmission to psychiatric hospital. Epidemiology and Psychiatric Sciences, 25(2): 181-193.

This study was a case control study (Level 5) in the hierarchy of evidence.

Vigod, S., Kurdyak, P, Dennis, C. et al. (2013). Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. The British Journal of Psychiatry, 202(3): 187-194. DOI: 10.1192/bjp.bp.112.115030.

This systematic review is another study at the highest level of strength in the hierarchy of evidence (Level 1).

Results of the Studies

The study by Kalseth et al. (2016) found that "the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas." The researchers also acknowledged a lack of studies that analyze the relationship between payment model and readmissions and suggest that financing systems could be a major variable in readmission rates. This is applicable to the PICOT of the EBP because the Eric Coleman care transition model is based on the idea of utilizing services to ensure optimum communication and care for continual, safe, quality care through periods of transition for the patient so that readmission does not become an issue. As this study indicates, environmental factors are unique in many cases for patients and must be considered on a case by case basis. In other words, there is no one-size-fits-all patient approach for transitions: providers must assess each patient's needs individually in order to ensure a smooth transition and to mitigate the risk of readmission of patients.

Vigod et al. (2013) found that "effective intervention components were: pre- and post-discharge patient psychoeducation, structured needs assessments, medication reconciliation/education, transition managers and in-patient/out-patient provider communication." These findings are applicable to the PICOT because they show precise areas of focus that should be addressed by transition managers using the Coleman model to reduce the risk of readmission.

Burns et al. (2013) found that "compulsory supervision does not reduce the rate of readmission of psychotic patients" in their randomized controlled trial of 442 patients discharged from a hospital or CTO. This indicates that, in terms of the PICOT, compulsory supervision is not an effective tool in the Coleman model, and better transition management is required, including outreach, education, and communication; however, mandatory supervision (i.e., against the patient's will) is not supportive of mitigating risk of readmission.

The study by Tulloch et al. (2016) found that the type of psychological impairment is a factor in early readmission, as is the length of stay in the hospital prior to discharge. The study also found that the "high risk" time for readmission is the time "immediately subsequent to discharge" -- therefore, with the PICOT in mind, the time of transition that should receive the most focus from transition managers is that time identified here as high risk -- i.e. immediately after discharge, when patients are uncertain and may need additional advice via communications with transition managers.

Kripalani et al. (2014) found that "compulsory supervision does not reduce the rate of readmission of psychotic patients" but that "some multifaceted interventions have been successful in this regard." These multifaceted interventions include "having multiple components that span both inpatient and outpatient settings and delivery by dedicated transitional care personnel." These interventions require considerable care, time, support and resources and cannot be successful without a clear plan and management team. For the PICOT, this means that the operation must be clearly, succinctly defined with roles and objectives delineated and proper resources allocated.

Theoretical and Operational Review of Concept to the PICOT

As the studies show, transition management is needed in order to reduce readmission rates in the psych hospital. Concerns that should be addressed by the Coleman model include the degree of financing available to patients and the length of stay that the patient has had in the hospital. Environmental concerns should also play a part in the devising of an adequate transition model change (Kalseth et al., 2016).

Likewise, the nursing practice change should be considerably and carefully planned so that every known variable that could impact a patient's early readmission is addressed and nothing is left to chance (Kripalani et al., 2014). Moreover, the effective components of transition strategies should be highlighted. These include: patient psychoeducation, structured needs assessments, medication education, adequate transition support, and adequate levels of communication (Vigod et al., 2013). Strategies for increasing effective communication could include using telehealth technologies, electronic consulting, and electronic health records.