Transition care services are part of the continuum of care and play an important role influencing hospital readmissions (Taylor et al., 2020). The Centers for Medicare & Medicaid Services mandate that hospitals have a discharge planning process for all patients (Center for Medicare Advocacy, 2017). Discharge delays account for lower scores in patient satisfaction, missed revenue, and bottlenecks in patient transfers (Gray et al., 2016). Transition care services are instrumental in assisting the patient to the next level of care and therefore need to be timely. The National Quality Forum (2010) Safe Practice-15 expects that healthcare organizations benchmark, measure, and continuously improve the discharge process. The 2001 Institute of Medicine report, Crossing the Quality Chasm, described the costs associated with poorly coordinated care transitions. These transitions account for nearly 20% of Medicare readmissions within 30 days postdischarge. It is estimated that more than 75% of these readmissions are preventable and would result in an estimated cost savings of $12 billion per year (Health Affairs, 2012).
Patient satisfaction is an important outcome measure in today's healthcare climate. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey completed by patients rating their inpatient stay. HCAHPS results affect medical reimbursement and account for one fourth of the value-based purchasing score (HCAHPS, 2021).
A systematic review including 24 articles of 17,664 patients and meta-analysis of the effect of interventions on successful care transitions for older adults found that self-management activities (relative risk [RR] 0.81 [0.74, 0.89]), telephone follow-up (RR 0.84 [0.73, 0.97]), and medication reconciliation (RR 0.88 [0.81, 0.96]) had the greatest impact on reducing hospital readmissions (Tomlinson et al., 2020). Assisting patients to the next level of care requires a collaborative effort by all members of the healthcare team. Although members of the healthcare team may vary, a coordinated discharge process can reduce barriers that impact discharge times, patient flow, satisfaction scores, and readmission rates.
The Institute for Healthcare Improvement (2021) recommends that healthcare leaders focus on improving the patient experience by providing individualized, coordinated care, and care transitions. The Agency for Healthcare Research and Quality (2017) recommends the implementation of the Reengineered Discharge (RED) Toolkit to improve the discharge process. A nurse, serving in the role as discharge advocate using the RED Toolkit, coordinates the discharge plan with members of the healthcare team and creates the after-hospital care plan (AHCP) to educate and prepare the client for discharge (Table 1). The AHCP, one component of the RED Toolkit, is a low-literacy discharge instruction booklet containing contact information, including the patient's medical provider, a medication schedule, scheduled follow-up appointments and tests, list of tests with pending results, an appointment calendar, list of discharge diagnoses, and information about what to do if a problem arises. The RED Toolkit provides a framework for the discharge planning process.
According to the 2020 annual report from the American Joint Replacement Registry of the American Academy of Orthopaedic Surgeons in the United States, which includes data from American Joint Replacement Registry participating institutions, 1,897,050 primary and revision hip and knee arthroplasty procedures were performed in the United States between 2012 and 2019 (American Academy of Orthopaedic Surgeons, 2020). In the United States, by 2030, revision total hip arthroplasty is projected to increase between 43% and 70%, and revision total knee arthroplasty is projected to increase between 78% and 182% (Schwartz et al., 2020).
In the tertiary hospital where this pilot study took place, more than 50% of the orthopedic patient discharges exceeded the desired discharge time internal benchmark of 2 hours. Discharge time is defined as the time the provider writes the order to the time the patient is discharged from the unit. Discharge time can significantly affect the throughput of patients admitted and transferred throughout the day. For example, on average, the pilot hospital emergency department held admitted patients 4 hours because of bottlenecks in the inpatient unit.
In this tertiary care hospital, the highest volume of discharges occurred on the orthopedic unit. More than 300 hip and knee surgeries were performed in 2016. The majority of discharges occurred in the afternoon typically just prior to 3:00 p.m. In addition, the 30-day readmission rate for hip and knee patients was 6% (fall 2017 data), and both Press Ganey and HCAHPS scores specific to discharge from the orthopedic unit were below the top-box scores. The overall patient satisfaction with the discharge process score from January 2017 to August 2017 was 33%, and only 2% of the patients felt ready for discharge. Further review of the healthcare organization revealed no standardized discharge process on the orthopedic unit. Thus, a feasible solution to improve the transition of care for orthopedic patients undergoing total hip or knee replacements or revisions was to implement and evaluate an evidence-based practice improvement (EBPI) project using the RED Toolkit.
The primary aim of this pilot project was to determine the impact of the RED Toolkit on patient knowledge for self-management, satisfaction with the discharge process, readiness for discharge, discharge time, and 30-day readmission rate following hip or knee joint replacement or revision surgery. Staff adherence using the RED Toolkit was also measured.
Method
The EBPI model was used to guide this project (Levin et al., 2010). The EBPI model integrates evidence-based practice and performance improvement into one model (Levin et al., 2010). The model consists of seven steps and allows for the practice change to be "tested" as a pilot. Steps 1 through 4 include description of the practice problem, development of a focused clinical question, searching for the highest level of evidence, and critical appraisal and synthesis of literature. The subsequent steps are to develop a goal statement, the plan-do-study-act (PDSA) cycle, and disseminate best practice (Levin et al., 2010).
Project Setting
The setting for this nurse-driven EBPI project was a 30-bed unit in a tertiary care hospital in an urban Midwest city. The primary patient population on the unit was orthopedic. The unit serves 12 orthopedic surgeons, two of whom primarily perform hip and knee surgeries. As noted earlier, in 2016, more than 300 hip and knee surgeries were performed. An orthopedic surgeon directs care for patients on their service. Upon discharge, patients may receive outpatient therapy or home health care, or be discharged to a skilled nursing facility or rehabilitation setting. The staff on the orthopedic unit consisted of a unit director, 5 lead registered nurses, 41 registered nurses, 19 nursing assistants/patient care technicians, an orthopedic case manager, physical therapists, occupational therapists, social workers, and a resource utilization coordinator. None of the registered nurses held the certified rehabilitation registered nurse (CRRN) credential.
Participants
All adult patients ages 18 years and older who planned for a discharge to home and underwent a hip or knee joint replacement or revision surgery were invited to participate in the project. Patients who were under the age of 18 years and those without a home disposition were excluded. Institutional review board approval was obtained prior to implementation of the project. The pilot was conducted in the spring 2018.
A clinical question utilizing the PICOT format was developed to assist in evaluating a possible outcome to the clinical problem: Among adult patients on an orthopedic unit, how does the use of the RED Toolkit, compared to current practice, affect patient knowledge for self-management, patient satisfaction with the discharge process, patient readiness for discharge, discharge time, and 30-day readmission rate of individuals undergoing a hip or knee joint replacement or revision? A thorough review of the literature was conducted using key words discharge, orthopedic, coordinator, hospital discharge, nursing, nurse, length of stay, discharge planner, patient satisfaction, discharge coordinator, discharge planning, and nursing staff combined with the Boolean connector AND. A total of 52 abstracts were reviewed, and 11 contained evidence related to the clinical question. Upon further examination of the literature, a second search was deemed necessary to learn more about the RED Toolkit. Key words re-engineered discharge, reengineered discharge, red toolkit, and project red were used with the Boolean connector OR. Thirty-four articles were reviewed, and eight were found to be relevant to the topic. Articles were critically appraised, evaluated, and summarized using the rapid critical appraisal method by Melnyk and Fineout-Overholt (2019). A total of 19 articles were used as evidence, with levels of evidence ranging from a Level 1 to a Level 7 (Melnyk & Fineout-Overholt, 2019).
The PDSA cycle was used for the project. In spring 2018, an initial meeting was held with the chief nursing officer (CNO) to review the purpose and goals of the project, discuss outcome measures, and determine team members for implementation.
Subsequent meetings were held with the CNO and the unit director to discuss the project and determine lead nurses on the unit to serve in the role of discharge educator. An e-mail to introduce stakeholders to the project with an invitation to a kickoff meeting was developed. The implementation team included the CNO, the unit director, the project leader, lead registered nurses, and the orthopedic case manager registered nurse. The project leader directed the implementation process and conducted the team meetings. An interdisciplinary discharge planning team was in place on the orthopedic unit and consisted of the lead nurse, orthopedic case manager, social worker, physical therapist, occupational therapist, and utilization review nurse. The interdisciplinary team met Monday through Friday to discuss the discharge planning needs of each patient on the unit. The CNO set a goal to decrease the readmission rate by 50% and targeted a readmission rate for hip and knee replacement and revision patients of 3% from the current 6%.
A representative from Quality Management was responsible for data collection of readmission rates. A process map of the discharge workflow was created with the members of the team and revised to eliminate duplication. Because the project was a pilot, it was determined that no changes would be made to the discharge documents. During the kickoff meeting, each of the 12 components of the RED Toolkit were reviewed and compared to current practice. Team responsibility was assigned (see Table 1). A significant part of the planning phase included organizing and training discharge educators, the orthopedic case manager follow-up telephone caller, and other stakeholders.
A kickoff meeting on the unit with a PowerPoint presentation to introduce the RED Toolkit was held. Discussion included the goal, implementation timeline, education plan, assignment of RED components, review of the discharge workflow, generation of the AHCP, and outcome documentation. The CNO, unit director, and eight members of the interdisciplinary team attended. Meeting feedback was used to make changes. These included incorporating often needed contact information given to orthopedic patients and the smoking cessation number. Individual educational sessions were provided to three nurse leaders on their scheduled shifts by the project leader.
The project was conducted in April 2018 after education of the staff. Five lead nurses served in the role of discharge educator. Lead nurses served the unit through their clinical leadership and typically did not have a patient care assignment. They were responsible for admitting new patients and assisting with the workflow of the unit. One lead nurse was assigned to each shift. Scheduled hip and knee surgeries occurred on Mondays, Tuesdays, and Thursdays.
The orthopedic case manager was in an established role conducting pre- and post-op education as well as follow-up phone calls for hip and knee joint replacement and revision patients for the two orthopedic surgeons. The orthopedic case manager also served in the role of discharge educator. It was determined that most RED components were part of the case manager responsibilities.
The project leader completed the process evaluation, rounding on the orthopedic unit Monday through Friday, attending the discharge planning meetings, as well as weekly discussions with the day shift lead nurses and orthopedic case manager. Process evaluation was completed by asking the discharge educator questions about the process and providing clarification as necessary. Specific discharge educator questions concerned conducting a follow-up phone call (1) if the patient was seen in the clinic within 72 hours postdischarge or (2) if the patient was discharged to a facility. These concerns were discussed with the project manager.
Final evaluation included results from outcome measures and feedback from the discharge educators. Knowledge for self-management was measured by those patients who completed a postdischarge follow-up phone call and correctly reported the reason for their hospital visit, symptoms to watch for, other medical tasks for their condition, and how to correctly take their medicines. Patient satisfaction was measured as the percentage of hip and knee joint replacement and revision patients who rated their satisfaction with the discharge process a 9 or 10 on a 1-10 scale during the follow-up phone call. Patient readiness was measured as the percentage of hip and knee joint replacement and revision patients who rated readiness for discharge a 9 or 10 on a 1-10 scale during the follow-up phone call. Readmission rate data were obtained from the hospital quality management department. Discharge time was provided by the unit director. Staff RED Toolkit adherence was determined by the project leader based on the number of components completed.
Results
Descriptive statistics were used to summarize the quantitative data. Thirty six patients were approached to take part in the project with 30 providing informed consent to participate from April 2018 to May 2018. Most participants had joint replacement surgeries with 36.7% (n = 11) total knee replacements, 33.3% (n = 10) total hip replacements, 16.7% (n = 5) knee revision surgeries and 13.3% (n = 4) hip revision surgeries. Most subjects were women (60%). Patient age ranged from 47 to 78 years, with a mean age of 63 years. The majority of subjects had private insurance (53.3%).
Knowledge for Self-Management
Knowledge for self-management was obtained for 27 of 30 (90%) participants. Each of the categories, knowledge of diagnosis and knowledge of symptoms, were scored at 92.6%. Participant knowledge of medications was 85.2% (see Table 2).
Patient Satisfaction With the Discharge Process
Sixteen patients (59.2%) rated their satisfaction with the discharge planning process as a 9 or 10. Satisfaction scores ranged from a minimum of 2 to a maximum score of 10, with a mean of 8.56 and a standard deviation of 1.93 (Table 3).
Patient Readiness for Discharge
Sixteen participants (64%) rated their readiness for discharge as a 9 or 10. The distribution of readiness for discharge scores ranged from a minimum of 2 to a maximum of 10, with a mean score of 8.36 and a standard deviation of 2.45 (see Table 3).
Discharge Time
The discharge time ranged from 30 minutes to 11.01 hours, with an average of 5.67 hours. Three patients were discharged less than 2 hours after the discharge order was written. Twelve patients were discharged between 3 and 6 hours, and 15 patients left the unit more than 6 hours after the written discharge order. All 30 patients received a follow-up phone call from the orthopedic case manager; however, only 14 patients (46.6%) received phone calls within the target 72-hour time frame.
Thirty-Day Readmission Rate
The 30-day all cause readmission rate was 3.3% based on 30 participants. The majority of patients (96.7%) did not require readmission; one patient was readmitted. Another participant visited the emergency department within 30 days of discharge.
Staff Adherence
Staff adherence with all 12 components of the RED Toolkit was 86.8%. Scheduling appointments for follow-up care was 86.8%. In three instances, the patients left the orthopedic unit before meeting with the lead nurse to receive the AHCP (see Table 4).
Discussion
Understanding and addressing project facilitators and barriers are necessary elements for the successful implementation of an evidence-based practice quality improvement project in the clinical environment. System and clinician facilitators included administrative support, the interdisciplinary discharge team, and the total hip and knee orthopedic process improvement team. Patients were facilitators because of their willingness to receive information about care related to their diagnosis and post discharge follow-up. Barriers to implementation at the system and clinician level included the lack of knowledge about role expectations, inadequate resources, concern about role overlap among team members related to discharge planning, resistance to change, lack of knowledge needed to implement the change, time to complete the required steps, and patient volume. Patient barriers included leaving the unit without meeting with the discharge nurse and self-reported outcomes.
Patient Knowledge for Self-Management
This outcome consisted of three factors: knowledge of how to correctly take medicines, knowledge of diagnosis, and symptoms to report. Although the target of 100% was not achieved, the results indicated that 100% of the patients had some level of understanding of their diagnosis whereas 92.6% had full understanding of their diagnosis and reporting symptoms. This finding is higher than reported by Jack et al. (2009) where 66% (198) of participants who received the RED Toolkit intervention understood their main problem or diagnosis. The biggest area for improvement was to increase patients' understanding of how to correctly take their medicine. The 85.2% project outcome is less than the 89% achieved for medication knowledge in the RED Toolkit intervention group of Jack et al. (2009) but closer to the usual care group at 83%. In the follow-up phone call, two participants indicated that they did not know how to take or wished they had more instruction on how to administer a low molecular weight heparin.
Patient Satisfaction With the Discharge Process
The project demonstrated improvement in patient satisfaction with the discharge process from 33% to 59.2%. This reflects those participants who rated their satisfaction 9 or above. Of note is that the mean satisfaction score was 8.56 +/- 1.93. Satisfaction is a key factor in the value-based purchasing score. Two project participants stated they were dissatisfied because of delays in staying on the unit to be seen by other departments prior to discharge. This outcome supports the need to secure "just-in-time" patient satisfaction information, that is, information obtained while the patient is still on the unit or shortly after discharge, in order to respond readily to patient concerns.
Patient Readiness for Discharge
A noted improvement occurred in patient readiness for discharge from 2% to 64%. This is indicative of those participants who rated their readiness 9 or above. This outcome is consistent with the findings of Jack et al. (2009) where self-reported preparedness of the RED Toolkit intervention group was 65%. Two participants indicated they could not assign a number to their readiness for discharge. A comment from one individual stated that, although they felt medically ready for discharge, they did not feel emotionally ready. Two participants wished they could have stayed one more day. Premature discharge is a factor strongly associated with readmission (Alper et al., 2020). Two participants indicated they could have benefited from more therapy. The need for more instruction on activity level was expressed by two patients. Further exploration on the delivery of therapy services might be warranted to improve this variable.
Discharge Time
The discharge time outcome measure within 2 hours of the written order before 11:00 a.m. was not met. Only three participants left the unit within 2 hours of the written discharge order, and no patients left before 11:00 a.m. Fifty percent of the patients left the unit 6 hours after the written discharge order. Delays were attributed to waiting for a consultant, pharmacy delivery, and transportation. There were 22 orders written before 9:00 a.m., which indicated that it was feasible to accomplish the goal for this population. However, the problem of discharge time continued to challenge the unit, creating bottlenecks in patient flow. Given that some patients returned to the unit as late as 7:00 or 8:00 p.m., it may be necessary to reevaluate this goal to ensure that therapy treatments and discharge instructions can be provided to the patient at all times.
Thirty-Day Readmission Rate
The outcome measure regarding 30-day readmission rate did not meet the benchmark of 3% but was close to the target goal. One participant (3.3%) was readmitted out of 30.
RED Toolkit Adherence
Although adherence with the RED Toolkit components was almost 90%, three participants did not receive the AHCP because they left the unit prior to meeting with the lead nurse. This is a similar finding reported by Jack et al. (2009) in which 83% (306) of the patients left without an AHCP. Participant-reported outcome data for this project were obtained from 26 of the 30 patients (86.8%) compared to 615 of 738 (83%; Jack et al., 2009). Gaps occurred in the completion of the follow-up phone call within the required time frame because of limitations of the orthopedic case manager. Although the orthopedic case manager valued completing the RED components, time and patient volume were barriers.
The orthopedic case manager reported to the orthopedic service and had out-patient as well as inpatient responsibilities. In addition, there was no coverage provided in the absences of the individual unless for prescheduled extended periods of time. These factors contributed to the 46.7% call rate within 72 hours. Recommendations to improve compliance in this area included establishing a champion responsible for each RED component, prioritizing the inclusion of RED components in the discharge planning process, and implementing the RED Toolkit in phases.
Final evaluation demonstrated that the RED Toolkit intervention was helpful in improving patient knowledge of self-management, satisfaction with the discharge process, and readiness for discharge. Feedback from the discharge educators included a need to reduce discharge workflow redundancies, address resource barriers, such as the lack of in-house support for the orthopedic case manager to assist with the discharge planning process, and the lack of technology to create an electronic AHCP.
Further rollout could include all patients on the orthopedic unit and the establishment of policies to coordinate and integrate RED components within the healthcare system. The act phase of the PDSA cycle gave the implementation team an opportunity to review the role of the discharge educator and determine if the RED components should be assigned to one or more individuals or be shared by members of the interdisciplinary team.
Limitations
Limitations of the project included a small sample size, the use of only one unit, and the implementation of the RED Toolkit in one urban Midwest hospital. This study included only orthopedic patients; thus, the results may not be generalizable to other patient groups. Other limitations included the lack of reliable/valid data collection tools and limited information technology to create electronic forms and reliance on participant self-report for outcomes.
Conclusions
Hospitalization and the follow-up care required for a patient can leave patients and caregivers overwhelmed. The costs of poorly coordinated care transitions impact length of stay, emergency department visits, hospital readmissions, patient experience, and care needs after discharge. The critical appraisal of the evidence indicates that discharge planning should be patient-partnered, involving the patient and family caregiver. All members of the healthcare team play an integral role in the transition of care to the next level. The RED Toolkit provides organizations a mechanism to coordinate discharge. The RED Toolkit provides a framework for the essential components that need to be included in preparing the orthopedic patient for discharge and rehabilitation. The rehabilitation nurse, who plays an important role in preparing patients for discharge, is in a key position to serve as the discharge advocate. Consideration should be given to assigning a champion to each RED component or prioritizing the components and rolling them out in phases. Integration of the AHCP into the electronic medical record is a necessary step for full integration of the RED Toolkit. A review and elimination of redundant forms streamlines workflow. Establishing an interdisciplinary team with strong leadership support, an empowering hospital culture, and commitment to the RED Toolkit can achieve improvements in discharge planning by decreasing discharge time, facilitating transition to home and reducing all-cause readmissions. Recommendations for further study include use of the RED Toolkit on all orthopedic patients as well as patients with spinal cord or traumatic brain injury.
Key Practice Points
* The RED Toolkit is effective in improving patient knowledge, satisfaction, and readiness for discharge in patients who had a total hip or knee replacement or revision surgery.
* All members of the healthcare team, especially the discharge and rehabilitation nurse, play an integral role in the transition of care for patients undergoing a joint replacement or revision.
* Findings from this pilot project are useful in developing a standard discharge process for all orthopedic patients within the healthcare system.
Conflicts of Interest
The author declares no conflict of interest.
Funding
The author declares that there is no funding associated with this project.
Acknowledgments
The author thanks Dr. Eileen Walsh for her assistance in the review of the article.
REFERENCES