Literature Review and Appraisal

Reducing the cases of readmissions among patients

by

Mehrnoosh Ejlali

Evidence-based Practice Project

Submitted to the Faculty of NUR 49800 Capstone Course in Nursing

College of Nursing

of Purdue University Northwest,

Hammond, Indiana

in partial fulfillment of course requirements for the degree of

Bachelor of Science

Month, 20xx

© copyright

Mehrnoosh Ejlali

20xx

all rights reserved

acknowledgments

Begin optional acknowledgments here.

table of contents

Section Page

acknowledgments iii

table of contents iv

abstract v

Sections

1. Introduction 1

2. Review of Literature and Synthesis of the Evidence 4

3. Plan for Implementation xx

4. Plan for Evaluation xx

5. Conclusions, Recommendations and Implications xx

references xx

appendices (If Applicable)

Appendix A – Put Title Here xx

List of tables

Table Page

Table 1 Summary of Reviewed Evidence……………………………………………………...9

Table 2 Put Name of Table Here xx

Table 3 Put Name of Table Here xx

ABSTRACT

Begin writing abstract here. APA abstracts begin on margin and do not indent. Please use headings in instructions

SECTION 1

Reducing the cases of readmissions among patients.

One of the issues that are affecting the healthcare sector is readmission. When a patient is readmitted, it means that there is a high possibility that the healthcare practitioners failed to intervene effectively. A person might be readmitted because he or she did not fully recover from the previous illness. Also, a person may be readmitted because healthcare practitioners might have missed the cause of the illness. Therefore, it means that they might have administered care that is not in line with the issue of the patient.

Purpose

The purpose of the research topic is to ensure that the problem at hand is addressed. The title of the research is trying to look for ways in which the number of readmission cases can be significantly reduced. In this case, it becomes evident that the topic of research or the research is looking for an intervention to a specific issue. The issue at hand is associated with readmissions, and the intervention is to reduce the number of readmission cases. The research also plays an essential role in informing people or the audience about the issue of readmission (Zuckerman, Sheingold, Orav, Ruhter, & Epstein, 2016). The healthcare sector has been suffering because of the increasing numbers of readmissions. When the numbers of readmissions continue to increase, it means that patients start to lose faith and trust in the healthcare sector fraternity. When research focuses on an issue, it does so because it wants people to know more about the issue and to identify the best ways to deal with the issue.

Relevance/significance

In the United States, there have been cases of readmissions, and most of them are associated with incompetent healthcare practitioners. The significance of the research is seen in the goals that it helps to meet. The research is relevant to the course in different ways. First, the research has focused on an issue that is associated with the healthcare sector. Therefore it means that the research findings will be addressing the right audience. Second, the research has taken a position that is essential in the field of healthcare. Healthcare practitioners and professionals have a higher calling than only offering care to patients (Figueroa, Joynt, Zhou, Orav, & Jha, 2017). They are also expected to look for solutions to the problems that might be affecting patients. The significance of the research can be tired of the direction and perspective it has taken. The research is aimed at bringing a solution on the table, and that means that it will be of benefit to the readers and targeted audience (Zuckerman et al. 2016). Also, the research has touched on an issue that is affecting patients not only in the country but also in different parts of the world. The mentioning of the problem creates awareness among healthcare practitioners in different parts of the world.

Potential outcomes

ABC Health Care Centre is determined to analyze the issues surrounding the cases of patient’s readmission and come up with a long term solution to curb this issue. The study will highlight on the essential strategies which should be embraced in the health care facilities so as to reduce the cases of readmission.

Clinical question

In hospitalized patients of all ages, how effective is providing early discharge plan with proper discharge education and follow up after discharge compare to patients who don’t get right information and no discharge follow up on decreasing rate of readmission in hospitals?

Section 2

Introduction

This section focuses on the review of literature related to this research. It explores on a review of past studies done on patient’s readmission issues. Emphasis is on the measures to minimize the concept of readmission in the hospitals. The review also depended on theoretical literature such as books, research papers, magazines, health reports and information from the Internet. However, the concentration was more on google scholar articles and those from health reports. This was because the latter explored more on the level or extent to which patients have been readmitted in the hospitals. The remaining failed to identify why the patients are readmitted as well as what can be done to minimize this.

Therefore, different themes were described as per the previous authors a well as their contradictions and consistencies. The results from the above named were used to identify the existing gaps in the studies; thus, making them an intent on the study. Besides the section covers the findings of the study and later a well-illustrated summary of the evidence was derived. Strategy of appraisal was Melnyk’s observational-analytic designs level of evidence. Level I had three sources, level II two source, level IV one source, and level V one source.

Review of Literature and Synthesis of Evidence

The papers problem, intervention, as well as comparison and its link to an outcome (PICO), involved the evaluation metrics regarding groups on the issue of patient's readmission. This primarily focused on a thirty-day experience in the management of patients being readmitted in the hospitals. However, PICO elements involved population; that is, in surgical patients facing complications, how effective is reduced hospital penalties compared to surgical initiatives, in reducing complications that results to patient’s readmission?

Besides the intervening interest in this involved effectiveness of reduced hospital penalties compared to surgical initiatives. Despite this, the intervention's comparison failed to link reduced hospital penalties to surgical initiatives. The latter marked the outcome of decreasing rates complications that results to patient’s readmission. Therefore, there was the intent to minimize if not end the rate of patient readmission in the hospitals; if possible, within a time limit of thirty days after the first discharge.

However, to address the PICO questions, the literature review was based on key terms; that is, patient discharge, rate of readmission, care of transitions, and post-acute care. Concerning the health care projects, the focus was on the National Readmissions Database (NRD) as well as the google scholar articles. Attention was based on this to bring different and vital meaning when It comes to analyzing different categories of readmission rates in patients. However, this assumes an expected hospital stay pay.

Common Themes in the Literature Review

By analyzing the data in the National Readmissions Database, a reveal of common topics was evident. These included arising of penalty fees in hospitals, surgery performance, and surgical initiative to avoid readmissions.

Arising of penalty fees in hospitals

Earlier, research in hospitals was intended to develop techniques to make it easier to contemplate the impact of finances on patient's readmissions on current ecosystems (Goodwin et al., 2015). Several scholars agree in their studies that programs for readmission lead to penalize in the hospitals. This moves to a higher degree than even the excess expectations speculated in the hospitals.

Surgery Performance Intervention with Hospital Penalties

Goodwin et al. (2015) say the primary issue noted has raised many readmissions with the performance of a joint surgery especially for the older population of adults from complications resulting from mobile follow-ups lacking to be initiated by a hospital health professional after discharging patients home. Health centers experience a minimal payment from Medicare because of government programs that initiate penalties where there is more readmission of patients in thirty days in their final hospital period. 18% of those under Medicare and are discharged from health care facilities must be readmitted hence, accounting for not less than fifteen billion spent according to report from MPAC (Goodwin & Ford, 2018). Health centers have not provided an estimate although different other officials have done it locally. For instance, US hospitals recorded more fines in 2013 compared to 2014 despite having not paid other fees since then (Shams, Ajorlou, & Yang, 2015).

Surgical Initiative to Avoid Readmissions.

Readmission issues had been noticed from the adult populations in the surgery process because of dislocations and falls. Research indicated that most of the readmissions can be prevented by follow-ups after initial hospital visitations. Initiatives that can boost the quality of care comprised of assessing for hospital rates of readmission (Tapper & Volk, 2017). The general unplanned sessions for readmission had been four percent in thirty days as well as seven percent in ninety days from a survey done after surgery of total hip arthroplasty (Pham, Li & Williams, 2016). However, prevention for readmission is achievable through a follow as well as planning the discharge effectively after the initial hospital visit. The is a need for exploring better ways to boost the little efforts put in reducing readmission.

Consistencies and Contradictions in The Literature.

Shaheen et al. (2019) argued that patient's readmissions in the hospitals have been a concern that is alarming as far as health care is involved. There has been a lack of compatibility in secondary patient's diagnosis and how eligible they should emerge. This makes the consistency of measuring their features to fail thus, reducing the ability to minimize the risk of mortality rate for readmitted patients. Besides, minimal preventable readmissions are associated with more significant complications (Arora et al., 2017). This has been confusing since no essential differences are found or rates of preventable admissions.

Existing Gaps in The Literature Review

Few research studies had focused on the significance of reducing the readmission of patients thus, major contradicting factors emerge. Hence, there were no consistent measures that had been discovered or approved on minimizing the rate of readmissions with improved performance in finance. This is because various scholars have explored the level or extent to which patients have been readmitted in hospitals. Despite they fail to identify why the patients are readmitted as well as what can be done to minimize this (Tapper et al., 2016). There was also a lack of national information represented in hospital rates of readmissions for different age brackets. NRD comprised data that approximated eighteen million patient's discharge that occurred in a single year.

Findings

Based on the reviewed literature, it is clear that an effective measure to reduce readmissions of patients can be implemented in the policies of health care. With this being made permanent, the challenge can be stopped as most of the causes will have been fought. Shams, Ajorlou, & Yang, (2015) argue that professionals in health sector must be concerned about the welfare of patients discharged through making follow-ups. Perhaps the clinicians can be grouped to make a follow-up of a different patient who is discharged initially

PICO Question: “In hospitalized patients of all ages, how effective is providing early discharge plan with proper discharge education and follow up after discharge compare to patients who don’t get right information and no discharge follow up on decreasing rate of readmission in hospitals?”

Key words: Patient's discharge, rate of readmission, care of transitions, and post-acute care.

Databases Searched: Google scholar articles and National Readmissions Database

Table 1

Summary of Reviewed Evidence

Author(s) and Date of Publication ONLY	Sample/Setting/ Design	Data Collection Tools	Findings/Results	Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions	Level of Evidence (LOE)
(Pham, Li, & Williams, 2016)	Design: Clinician guideline Setting: Hospital settings Sample: N=2 systematic reviews	Scales for risk assessment used in the 4 systematic reviews	1. Patients need to have support all through unhealthy periods-based ion the review	Strengths: Clinician guidelines are a high-level evidence. Weaknesses: The information from review might be inaccurate. Conclusions: Recommended guideline for further studies in patient’s readmissions	Level II (risk assessment scales)
Author(s) and Date of Publication ONLY	Sample/Setting/ Design	Data Collection Tools	Findings/Results	Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions	Level of Evidence (LOE)
(Shams, Ajorlou, & Yang, 2015)	Design: Literature review Setting: Readmission checklists in various hospitals Sample: N= 20 studies	Single interventions in questionnaires	1.Male patients are less readmitted compared to women	Strengths: Study interventions appraised of quality through use of questionnaires Weaknesses: The information in questionnaire might be inaccurate Conclusions: Some single intervention studies could not demonstrate impacts.	Level I
(Goodwin & Ford, 2018)	Design: Literature review Setting: Long-run and acute care Sample: N= 17 studies	Case studies analyzation	1.The rate of patient surgery has increased. 2.15 reports prove on surgery improvements	Strengths: Analyzed studies were quality based on Clinicians reports. Weaknesses: Some information omitted for confidentiality. Conclusions: Acute care prevention can minimize surgery rates	Level I
Author(s) and Date of Publication ONLY	Sample/Setting/ Design	Data Collection Tools	Findings/Results	Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions	Level of Evidence (LOE)
(Tapper & Volk, 2017)	Design: Systematic review Setting: Worldwide hospitals Sample: N=30 studies in 7 different nations.	Experimental designs from electronic databases.	1.Children follow in readmission process. 2.Interventions were multiply used in major studies.	Strengths: Quality assessed using criteria published in clinical guidelines Weaknesses: Confidence level was low studies as they were very simple. Conclusions: Studies reveal on no course of action planned.	Level II
(Pham, Li, & Williams, 2016)	Design: Longitudinal research Setting inapplicable Sample inapplicable	Survey	1.Most of the readmissions are unplanned	Weakness: A great population is ignored in the study	Level IV
Author(s) and Date of Publication ONLY	Sample/Setting/ Design	Data Collection Tools	Findings/Results	Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions	Level of Evidence (LOE)
(Tapper, & Volk, 2017)	Design: Cohort prospective study Setting: 19 units	Case study	1.Financial support in hospitals result to clinicians being less careful in surgery	Strengths: The study had a powered sample size with 486 patients (N=150 in similar studies). Weaknesses: No randomization as well as control groups. Conclusions: Interventions involved a bundle of care exercised by nursing staff.	Level V
(Goodwin et al., 2015)	Design: Cluster randomized controlled trial (RCT) Setting: secondary hospitals Sample: N= 5 secondary hospitals	Data collected through assessment tools based on demographics.	1.Cesarean method might cause women readmission to hospitals	Strengths: Strength of women undergoing the process. Thus, advanced technology used. Weaknesses: Small number leads to irrelevance of information. Conclusions: Major significant effects after C-method left in most patients.	Level I
Author(s) and Date of Publication ONLY	Sample/Setting/ Design	Data Collection Tools	Findings/Results	Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions	Level of Evidence (LOE)
(Tapper & Volk, 2017)	Design: Clinician guidelines Setting: Worldwide settings Sample: N= 30 hospitals	Survey, case series, and quasi experiments	1.The principles of psychology have not been analyzed by the experts with regard to patients	Strengths: Highest level of evidence from clinical report and guidelines Recommendation strength provided. Weaknesses: Psychological information from case series might be pseudo. Conclusions: Interventions in the guidelines are recommended to be evidence based	Level V

Section 3

Plan for Implementation

Begin writing here.

Table 2

Estimated Timetable Blueprint for Implementation

Task	Estimated Date of Start	Estimated Date of Completion	Person Responsible

section 4

Plan for Evaluation

Begin writing here.

Table 3

EBP Evaluation Plan

Outcome(s)	Measures/Measurement	Time of Collection/Person Responsible

section 5

Conclusions, Recommendations and Implications

Begin writing here.

References

Arora, S., Patel, P., Lahewala, S., Patel, N., Patel, N. J., Thakore, K., ... & Shah, M. (2017). Etiologies, trends, and predictors of 30-day readmission in patients with heart failure. The American journal of cardiology, 119(5), 760-769.

Figueroa, J. F., Joynt, K. E., Zhou, X., Orav, E. J., & Jha, A. K. (2017). Safety-net hospitals face more barriers yet use fewer strategies to reduce readmissions. Medical care, 55(3), 229.

Goodwin, A. J., Rice, D. A., Simpson, K. N., & Ford, D. W. (2015). Frequency, cost and risk factors of readmissions among severe sepsis survivors. Critical care medicine, 43(4), 738.

Goodwin, A. J., & Ford, D. W. (2018). Readmissions among sepsis survivors: Risk factors and prevention. Clinical pulmonary medicine, 25(3), 79.

Pham, Q. H., Li, S. X., & Williams, B. C. (2016). Risk factors and effects of care management on hospital readmissions among high users at an Academic Medical Center. Care Management Journals, 17(3), 134-139.

Shams, I., Ajorlou, S., & Yang, K. (2015). A predictive analytics approach to reducing 30-day avoidable readmissions among patients with heart failure, acute myocardial infarction, pneumonia, or COPD. Health care management science, 18(1), 19-34.

Shaheen, A. A., Nguyen, H. H., Congly, S. E., Kaplan, G. G., & Swain, M. G. (2019). Nationwide estimates and risk factors of hospital readmission in patients with cirrhosis in the United States. Liver International, 39(5), 878-884.

Tapper, E. B., Finkelstein, D., Mittleman, M. A., Piatkowski, G., Chang, M., & Lai, M. (2016). A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clinical Gastroenterology and Hepatology, 14(5), 753-759.

Tapper, E. B., & Volk, M. (2017). Strategies to reduce 30-day readmissions in patients with cirrhosis. Current gastroenterology reports, 19(1), 1.

Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the hospital readmissions reduction program. New England Journal of Medicine, 374(16), 1543-1551.

APPENDICES

Begin here.