Pre- and Post-Discharge Techniques to Reduce Hospital Readmissions

Practice Issue

What practice issue has been identified related to the chosen topic?

Post-surgical oncology adult patients that do not undergo special pre-discharge education and do not have a planned follow-up with their primary care physician can have a higher rate of hospital readmissions.

What is the scope of the practice issue?

This health-related problem concerns immunocompromised adults and is included in the practice of nurses and general practitioners.

What is the practice area?


How was the practice issue identified?

  • Safety/risk management concerns
  • Unsatisfactory patient outcomes
  • Significant financial concerns

What is the rationale for the checked selections?

First of all, higher rates of readmissions show that patients may have post-surgical complications according to the lack of education and follow-ups. Second, when patients return to the hospital again, the medical establishment can lose a significant amount of money due to additional spending on hospitalization, procedures, and medication (Merkow et al., 2015). Third, the safety of patients who do not receive a sufficient education before being discharged puts them at risk. Returning patients can have some health-related issues that could be eliminated with preventive measures.

What evidence must be gathered?

  • Literature search
  • Standards

That is the rationale for the checked selections?

Literature search can provide an extensive amount of evidence regarding patient outcomes and their education and planning. Various studies with similar topics can be analyzed to devise a methodology for educating patients. Current standard practices of pre-discharge training can also be discussed to assess whether they are adequate to prevent readmission. Their benefits and drawbacks can reveal the need for a different system to be implemented.

Evidence Summary

The practice problem with reference to the identified population, setting and magnitude of the problem in measurable terms

The researched practice issue deals with post-surgical oncology adult patients. Standard education and planning that do not account for any special measures for immunocompromised patients can be ineffective in preventing readmission of these patients to the hospital. Moreover, the absence of follow-up plans with a PCP can also put some individuals at the risk of complications. On the other hand, individual pre-discharge planning and education performed by nurses along with a scheduled post-discharge follow-up may significantly reduce the risk of hospital readmissions. The implementation of these methods can be measured by the rate of readmissions for patients with and without education and follow-up planning.

Discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness

The objectives of the article

Hall et al. (2016) outline a number of objectives. The first one is the evaluation of discharge plans that are performed by a single assigned caseworker in comparison to the ones made by a non-specific caseworker. The second is their effectiveness in preventing hospital readmissions for acute respiratory exacerbations in children with asthma, bronchiectasis, and other chronic lung diseases.

A statement of the questions being addressed in the work

The authors discuss whether caseworkers assigned to individuals can create follow-up plans that could significantly reduce the possibility of children being hospitalized with complications following their discharge. The questions also include intervention practices such as self-management education and assessment, evaluation of various factors such as one’s well-being, lifestyle, and support network as opposed to focusing on symptoms and diseases. The presented practice issue is also concerned with preventive methods for lowering hospital readmissions. The educational plans described in the article correspond with the topic as they also center on the patients’ post-discharge living and self-management.

The interventions the authors suggest to improve patient outcomes

The authors suggest assigning specific caseworkers to children during their admission. These people’s roles would be to gather the information about the child’s health from the hospital staff and create an individual plan that could help the child after his or her discharge. Follow-up appointments would help the caseworker to understand if the child and the family can use this method. The specialist can correct some aspects of the individual plan, and analyze the risks of readmission. The approach would focus not only on the patient’s health, but also on his or her daily activities, family and friends, and emotional well-being. In theory, this method would help caseworkers to reduce the rate of complications, improve the communication between patients and service providers, and better understand the role and the needs of outpatient care.

The main findings by the authors of the systematic review including the strength of evidence for each main outcome

The chosen systematic review does not have any outlined findings as it is in its review state. However, the authors present a number of measures for their analysis. They ensure that any bias in their study will be noted and eliminated. The summary of findings will include such factors as the rate of hospitalizations due to exacerbations, patients’ quality of life after discharge, the cost-effectiveness of the approach, adherence to the medications prescribed after discharge, and patients’ mortality rates. This study is relevant to the project because it deals with similar types of outcomes.

Evidence-based solutions to be considered for the project

The main EB solution to the issue of readmissions is scheduling follow-ups for patients with possible post-operative complications. Merkow et al. (2015) argue that planned visits to the hospital can significantly reduce the possibility of hospitalization for returning individuals. Surgery outcomes should also be addressed with individual pre-discharge education for patients. These two solutions give patients an opportunity to stay informed about their condition and maintain the lifestyle that fits with their primary health concerns.

Limitations to the studies performed that impact the ability to utilize the research in the project

The study by Hall et al. (2016) discusses a rather narrow topic which can be considered a limitation for using it in this project. The outlined practice issue is concerned with adults with oncologic problems, while the article discusses the issues of children with chronic respiratory conditions. The use of a caseworker and not a nurse may also be a limiting factor as it places different responsibilities on the members of the hospital staff.


Hall, K. K., Chang, A. B., & O’Grady, K.F. (2016). Discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness. Cochrane Database of Systematic Reviews, 8. Web.

Merkow, R. P., Ju, M. H., Chung, J. W., Hall, B. L., Cohen, M. E., Williams, M. V.,… Bilimoria, K. Y. (2015). Underlying reasons associated with hospital readmission following surgery in the United States. JAMA, 313(5), 483-495.

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