Discharge Planning- November 2013

Table of Contents

Cochrane Systematic Reviews.

Admission Prevention.

Bed Management

Capacity Planning.

Discharge Coordination.

Discharge Process.

Education and Practice.

Estimating Dates for Discharge.

Multidisciplinary Team Discharges.

Nurse Led Discharge.

Patient Centred Discharge.


Simple Discharges and Complex Discharges.


Trust Information.

Cochrane Systematic Reviews

SHEPPERD SASHA, LANNIN NATASHA, A., CLEMSON LINDY, M., MCCLUSKEY ANNIE, CAMERON IAN, D. and BARRAS SARAH, L., 2013.Discharge planning from hospital to home. Cochrane Database of Systematic Reviews, (1),
Abstract: The aim of this study was to determine the effectiveness of planning the discharge of individual patients moving from hospital.The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates.
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Admission Prevention

BURNS, C., 2013. Reducing hospital admissions from care homesNursing times, 109(1/2), pp. 23-
Abstract: Admission to hospital can be a frightening experience for care home residents, and is often unnecessary. To reduce avoidable attendance/admissions, a community matron for care homes role was developed. The service has significantly reduced avoidable attendance/ admissions and has improved care quality.

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Bed Management

IMISON, C. and THOMPSON, J., 2012. Older People and Emergency Bed Use: Exploring VariationLondon: Kings Fund:

Abstract: This paper explores factors that might be driving the significant variation in use of hospital beds by patients over 65 admitted as an emergency.

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Capacity Planning

Nothing to report

Discharge Coordination

DEAN, E., 2013. Smooth transitionsNursing Standard, 27(24), pp. 20-2
Abstract: Patient discharge from hospital is often delayed by poor planning, a lack of integration between health and social care and a shortage of services. In this article, experts explain flaws in current systems and nurses reveal practical solutions they have introduced to prevent costly and distressing delays.
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Discharge Process

CMS gives tips on discharge planning. 2013. Hospital Case Management, 21(8), pp. 112-114Full Text

CMS updates discharge planning guidelines. 2013. Hospital Case Management, 21(8), pp. 106-113Full Text

IMs gain importance as CMS focuses on dischargeplanning. 2013. Hospital Case Management, 21(8), pp. 101-102. Full Text

BILLINGS, J., GEORGHIOU, T., BLUNT, I. and BARDSLEY, M., 2013. Choosing a model to predict hospital admission: an observational study of new variants of predictive models for case findingBMJ open, 3(8), pp. e003352-2013-003352
Abstract: Data set analysis to test the performance of new variants of models to identify people at risk of an emergency hospital admission. These models provide a basis for wider application in the National Health Service. Each of the models examined produces reasonably robust performance and offers some predictive value.Full Text

DEBONO, R., PAUL, S.P. and HEATON, P.A., 2013. Children discharged against medical adviceNursing Times, 109(31/32), pp. 20-22
Abstract: This article describes a recent retrospective case note (audit) study of Discharge against medical advice (DAMA) in paediatric patients attending a district general hospital, followed by a literature review. It also discusses the legal implications of DAMA and offers some strategies for clinical practice.
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FOX, M.T., PERSAUD, M., MAIMETS, I., BROOKS, D., O'BRIEN, K. and TREGUNNO, D., 2013. Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysisBMC Geriatrics, 13
Abstract: In this systematic review, the effectiveness of early discharge planning to usual care in reducing index length of hospital stay is compared. Service providers can use these findings to design and implement early discharge planning for older adults admitted to hospital with an acute illness or injury.
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HESSELINK, G., VERNOOIJ-DASSEN, M., PIJNENBORG, L., BARACH, P., GADEMAN, P., DUDZIK-URBANIAK, E., FLINK, M., ORREGO, C., TOCCAFONDI, G., JOHNSON, J.K., SCHOONHOVEN, L., WOLLERSHEIM, H. and EUROPEAN, H.A.N.D.O.V.E.R.,COLLABORATIVE, 2013. Organizational culture: an important context for addressing and improving hospital to community patient dischargeMedical care, 51(1), pp. 90-8
Abstract: Organizational culture is seen as having a growing impact on quality and safety of health care, but its impact on hospital to community patient discharge is relatively unknown. On the basis of the data, the researchers hypothesized that the extent to which hospital care providers value handovers and the outreach to community care providers is critical to effective hospital discharge.

HOLLAND, E., KNAFL, J. and BOWLES, H., 2013. Targeting hospitalised patients for early discharge planning intervention. Journal of Clinical Nursing, 22(19), pp. 2696-2704
Abstract: The purpose of the study was to describe the ability of an evidence-based discharge planning (DP) support tool to identify and prioritise patients appropriate for early DP intervention. Use of a support tool minimises biases inherent in decision-making and improves the opportunity for patients to access resources they need to promote successful recovery.


JACK B., PAASCHE-ORLOW M, MITCHELL S, 2013. Re-engineered discharge (RED) ToolkitAgency for Healthcare Research and Quality, 12(13),
Abstract: This toolkit provides information to help hospitals implement Project RED, including how to determine goals at the outset and measure project outcomes after implementation.Full Text

KONGKAEW C, HANN M, MANDAL J, ET AL., 2013. Risk factors for hospital admissions associated with adverse drug events. Pharmacotherapy, 33, pp. 827-837
Abstract: For decades, adverse drug events have been known to be a major cause of hospital admissions. This study identified specific predictors associated with preventable adverse drug event admissions, such as the amount of time since starting a new medication.Abstract

LEES, L., 2013. The key principles of effective discharge planningNursing times, 109(3), pp. 18-9.Full Text

MCALISTER, F.A., BAKAL, J.A., MAJUMDAR, S.R., DEAN, S., PADWAL, R.S., KASSAM, N., BACCHUS, M. and COLBOURNE, A., 2013. Safely and effectively reducing inpatient length of stay: a controlled study of the General Internal Medicine Care Transformation InitiativeBMJ quality & safety, 
Abstract: Whether improving the efficiency of hospital care will worsen post-discharge outcomes is unclear.A study was designed to test this hypothesis. The Care Transformation Initiative was associated with substantial reductions in Length of Stay without increasing post-discharge events commonly quoted as proxies for quality.
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MILLER, T., 2013.Discharge Planning - A Priority in the Care Delivery ProcessRehabilitation Nursing, 38(5), pp. 215-217
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PHO, K., 2013. Why can't we be more proactive in discharging patients? 
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SHUTTLEWORTH, A., 2013. Reduce harm when discharge advice is ignored. Nursing Times, 109(31/32), pp. 11.

SOONG, C., DAUB, S., LEE, J., MAJEWSKI, C., MUSING, E., NORD, P., WYMAN, R., BAKER, G.R., ZACHAROPOULOS, N. and BELL, C.M., 2013.Development of a checklist of safe discharge practices for hospital patientsJournal of Hospital Medicine (Online), 8(8), pp. 444-9
Abstract: A structured approach to discharge planning is described, starting from admission and proceeding through discharge, using a standardized checklist of tasks to be performed for each hospitalization day to create an evidence-based checklist of safe discharge practices for hospital patients.

THE HEALTH FOUNDATION, 2013.Improving Hospital Discharge for Dementia Patients
Abstract: My Discharge’ was launched at the Royal Free London NHS Foundation Trust in April 2013. Part of the Health Foundation’s 2012 Shine programme, the project aims to improve patient and carer experiences by ensuring that people with dementia stay in hospital for less time than those who do not have the condition.
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Education and Practice

GRAHAM, J., GALLAGHER, R. and BOTHE, J., 2013. Nurses' discharge planning and risk assessment: behaviours, understanding and barriersJournal of Clinical Nursing, 22(15), pp. 2338-2347
Abstract: Nurses ( n = 64) working in acute wards undertook a self-report survey of discharge planning understanding, adherence and barriers, in a study designed to assess nurses adherence to Discharge planning policy.

KORNBURGER, C., GIBSON, C., SADOWSKI, S., MALETTA, K. and KLINGBEIL, C., 2013. Using 'Teach-Back' to Promote a Safe Transition From Hospital to Home: An Evidence-Based Approach to Improving the Discharge ProcessJournal of pediatric nursing, 28(3), pp. 282-292
Abstract: The 'teach-back' process is a comprehensive, evidence-based strategy which can empower nursing staff to verify understanding, correct inaccurate information, and reinforce medication teaching and new home care skills with patients and families.

LEES, L., 2013. A guide for HCAs on safe patient transfers. Nursing times, 109(26), pp. 20-23
Abstract: This article is written predominantly for healthcare assistants. It may also be useful for anyone less familiar with transferring patients or who delegates to HCAs. It offers a definition of patient transfer and addresses considerations for patient safety and the role of HCAs throughout the three distinct phases of transfer.
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Estimating Dates for Discharge

FOX, M.T., PERSAUD, M., MAIMETS, I., BROOKS, D., O'BRIEN, K. and TREGUNNO, D., 2013. Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysis. BMC Geriatrics, 13Abstract: In this systematic review, the effectiveness of early discharge planning to usual care in reducing index length of hospital stay is compared. Service providers can use these findings to design and implement early discharge planning for older adults admitted to hospital with an acute illness or injury.
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Multidisciplinary Team Discharges

GAMBLE, S., 2013. An exploratory study of patient assessment within the discharge and rehabilitation team. International Journal of Therapy & Rehabilitation,20(6), pp. 294-301
Abstract: This study explores interdisciplinary working among nurses and allied health professions who have experience of crossing professional boundaries while undertaking the initial patient assessment within the discharge and rehabilitation teams. AHPs who undertake the initial holistic patient assessment would benefit from further training.
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Nurse Led Discharge

Nothing to Report

Patient Centred Discharge

BENCH, S., DAY, T. and GRIFFITHS, P., 2013. Effectiveness of Critical Care Discharge Information in Supporting Early Recovery From Critical Illness. Critical Care Nurse, 33(3), pp. 41-53
Abstract: INSET: CCN Fast Facts.
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JEUNGOK, C., 2013. Older Adults' Perceptions of Pictograph-Based Discharge Instructions after Hip Replacement Surgery. Journal of gerontological nursing,39(7), pp. 48-55
Abstract: The aim of this focus group study was to examine the acceptability and comprehension of these instruction using pictographs (i.e., simple line drawings with stick figures showing explicit care actions) to 15 low-literate older adults.
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MARIE THON, I., LIE, I. and HELLES¸, R., 2013. Nurses' perspectives on the discharge of cancer patients with palliative care needs from a gastroenterology ward. International journal of palliative nursing, 19(8), pp. 396-403
Abstract: People with cancer usually like to spend as much time as possible at home rather than in the hospital. Nurses have a pivotal role when patients are discharged to a unit in hospital or from hospital to the community health-care system.
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AHMAD, F.S., METLAY, J.P., BARG, F.K., HENDERSON, R.R. and WERNER, R.M., 2013. Identifying hospital organizational strategies to reduce readmissions.American Journal of Medical Quality, 28(4), pp. 278-85
Abstract: Hospital administrators are under pressure to implement strategies to reduce readmissions despite limited evidence of effective strategies. The objectives of this study were to understand the process of developing readmission reduction strategies and to identify and categorize the range of strategies being implemented. The results highlight the myriad approaches to readmission reduction and the complexity of developing effective strategies.

ANONYMOUS, 2013.A proactive approach to preventing readmissions. Hospital Case Management, 21(9), pp. 120-1
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BERRY JG, ZINIEL SI, FREEMAN L, ET AL., 2013. Hospital readmission and parent perceptions of their child's hospital dischargeInternational Journal for Quality in Health care, epub ahead of printAbstract: A prospective study of parents to describe parent perceptions of their child's discharge and assess the relationship with hospital readmission.Parent perception of their child's health at discharge was associated with the risk of a subsequent, unplanned readmission. Addressing concerns with this perception prior to hospital discharge may help mitigate readmission risk in children.Abstract

BERRY, J.G., TOOMEY, S.L., ZASLAVSKY, A.M., JHA, A.K., NAKAMURA, M.M., KLEIN, D.J., FENG, J.Y., SHULMAN, S., CHIANG, V.K., KAPLAN, W., HALL, M. and SCHUSTER, M.A., 2013.Pediatric readmission prevalence and variability across hospitals. JAMA, 309(4), pp. 372-80
Abstract: This study was designed to determine the prevalence of pediatric readmissions and the magnitude of variation in pediatric readmission rates across hospitals. There was significant variability in readmission rates across conditions and hospitals. These data may be useful for hospitals' quality improvement efforts.
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BLUNT, I. THE HEALTH FOUNDATION, NUFFIELD TRUST., 2013.Focus on preventable admissions: Trends in emergency admissions for ambulatory care sensitive conditions, 2001 to 2013Quality Watch, Abstract: One marker of success for health systems is their ability to control rates of emergency admission for conditions which can be preventatively managed. This study examines admissions across England over the 12-year period from 2001 to 2013 as an indicator of how well primary and preventive care were working to reduce emergency admissions.
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BURKE, R.E., KRIPALANI, S., VASILEVSKIS, E.E. and SCHNIPPER, J.L., 2013.Moving beyond readmission penalties: creating an ideal process to improve transitional careJournal of Hospital Medicine (Online), 8(2), pp. 102-9
Abstract: Hospital readmissions are common and costly; this has resulted in their emergence as a key quality indicator in the current era of renewed focus on cost containment. A conceptualization of the "ideal" discharge process could help address these deficiencies and move the state of the science forward.Abstract

DELAMATER, P.L., MESSINA, J.P., GRADY, S.C., WINKLERPRINS, V. and SHORTRIDGE, A.M., 2013.Do More Hospital Beds Lead to Higher Hospitalization Rates? A Spatial Examination of Roemer's Law. PLoS ONE, 8(2),
Abstract: Roemer's Law, a widely cited principle in health care policy, states that hospital beds that are built tend to be used. The study finds compelling evidence that a positive, statistically significant relationship exists between hospital bed availability and inpatient hospitalization rates.
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GRAHAM, L.E., LEFF, B. and ARBAJE, A.I., 2013. Risk of hospital readmission for older adults discharged on Friday. Journal of the American Geriatrics Society,61(2), pp. 300-1
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HANSEN, L.O., GREENWALD, J.L., BUDNITZ, T., HOWELL, E., HALASYAMANI, L., MAYNARD, G., VIDYARTHI, A., COLEMAN, E.A. and WILLIAMS, M.V., 2013.Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalisation Journal of Hospital Medicine (Online), 8(8), pp. 421-7.Abstract: This study was designed to determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay.Participation in Project BOOST appeared to be associated with a decrease in readmission rates.Abstract.

LONG, T., GENAO, I. and HORWITZ, L.I., 2013. Reasons for readmission in an underserved high-risk population: a qualitative analysis of a series of inpatient interviewsBMJ open, 3(9), pp. e003212-2013-003212Abstract: The objective of this study was to gather qualitative data to elucidate the reasons for readmissions in a high-risk population of underserved patients. These high-risk patients were receiving the formal services that they needed, but were making the decision to go to the ED because of inadequate access to care and fragmented primary care relationships.
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MARKLEY, J., ANDOW, V., SABHARWAL, K., WANG, Z., FENNELL, E. and DUSEK, R., 2013. A Project to Reengineer Discharges Reduces 30-Day Readmission RatesAmerican Journal of Nursing, 113(7), pp. 55-65
Abstract: A Texas hospital achieves improvement in its readmission rate by implementing Project RED.

MCALISTER, F., 2013.Decreasing readmissions: it can be done but one size does not fit allBMJ Quality and Safety, epub ahead of print Sept 2013
Abstract: Readmissions within 30 days of discharge are common, costly and hazardous—as such, efforts to reduce readmissions are a major focus in virtually all healthcare systems.Full Text

MCGHEE, D.J.M. ROYLE,P.L. COUNSELL,C.E. ET AL, 2013. Does a targeted bundle-of-care for inpatients with heart failure improve re-admission rates? Age and Aging, 42, pp. ii5
Conference abstract.

NAUMANN, DM. QUINN, M. & SIVANESAN, S ET AL, 2013.Preventing Readmissions: Are we doing enough? British Journal of Healthcare Management, 19(7), pp. 348
Abstract: Readmission to hospital within 30 days of discharge impacts adversely on patients' wellbeing, and increases treatment burdens in terms of human resources, logistics and cost. This is a retrospective review of consecutive surgical admissions to a single NHS unit readmitted to the same facility within 30 days of index admission between April and July 2012.Full Text

TOMS, M., 2013.Community matrons' views of readmissionNursing Times, 109(19), pp. 24-6
Abstract: Readmission to hospital is an expensive but common occurrence, This study analyses the opinions of community matrons who proactively manage NHS service users who are frequently admitted to hospital. The findings of this study back up evidence that more effective support of psychological and mental health needs of people with long-term conditions can lead to improvements in physical as well as mental health.
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TSAI, C., JOYNT, E., ORAV, E.,JOHN, GAWANDE, A. and JHA, K., 2013. Variation in surgical-readmission rates and quality of hospital careNew England Journal of Medicine, 369(12), pp. 1134-1143Abstract: Reducing hospital-readmission rates is a clinical and policy priority, but little is known about variation in rates of readmission after major surgery. This study demonstrates that hospitals with high surgical volume and low surgical mortality have lower rates of surgical readmission than other hospitals.Full Text

WILLIAMS, M.V., 2013. A requirement to reduce readmissions: take care of the patient, not just the disease. JAMA, 309(4), pp. 394-6
Abstract: Comment on Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia 
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Simple Discharges and Complex Discharges

ASKELSDOTTIR, B., LAM-DE JONGE, W., EDMAN, G. and WIKLUND, I., 2013. Home care after early discharge: Impact on healthy mothers and newborns.Midwifery, 29(8), pp. 927-935
Abstract: The objective of this study was to compare early discharge with home care versus standard postpartum care in terms of mothers' sense of security and breast-feeding duration. The study found early discharge with home care is a feasible option for healthy women and newborns, but randomised studies are needed to investigate the effects of home care on breastfeeding rates.
Full TextNote: You will need to register (free of charge) with Science Direct the first time you use it.

CLOONAN, P., WOOD, J. and RILEY, B., 2013. Reducing 30-Day ReadmissionsJournal of Nursing Administration, 43(7), pp. 382-388
Abstract: Strategies addressing low health literacy aimed at reducing 30-day readmissions are identified and discussed.Abstract.

DAVANZO, R., MONASTA, L., RONFANI, L., BROVEDANI, P. and DEMARINI, S., 2013. Breastfeeding at NICU Discharge: A Multicenter Italian StudyJournal of Human Lactation, 29(3), pp. 374-381
Abstract: Human milk is the optimal form of nutrition for infants, yet international data suggests that the use of human milk is limited in patients cared for in the neonatal intensive care unit (NICU). The study finds limited breastfeeding and use of human milk among the NICU infants at discharge.Abstract.

KNIGHT, A., THOMPSON, D., MATHIE, E. and DICKINSON, A., 2013.'Seamless care? Just a list would have helped!' Older people and their carer's experiences of support with medication on discharge home from hospital. Health Expectations, 16(3), pp. 277-292
Abstract: Improved medicines management during hospital discharge is required to ensure older people take their medications as prescribed and to protect them from the adverse effects of medicines not being taken correctly and help avoid unnecessary hospital re-admission.Abstract

MACNAUGHTON-DOUCET, J., 2013.Determinants of Health in Discharge Planning for Seniors: Asking the Right QuestionsCanadian Journal on Aging, 32(3), pp. 307-316
Abstract: Practitioners are encouraged to consider a shift in their philosophy regarding the manner in which interdisciplinary health care teams ask questions of seniors and their caregivers in the hospital discharge process. This approach may reveal strengths and also expose health and social inequities that seniors might face upon their arrival home.Abstract.

SMITH, V.C., HWANG, S.S., DUKHOVNY, D., YOUNG, S. and PURSLEY, D.M., 2013.Neonatal intensive care unit discharge preparation, family readiness and infant outcomes: connecting the dots. Journal of Perinatology, 33(6), pp. 415-422
Abstract: NICU discharge preparation is the process of facilitating comfort and confidence as well as the acquisition of knowledge and skills to successfully make the transition from the NICU to home. In this paper, the authors outline an approach to NICU discharge preparation to achieve discharge readiness.Abstract.


The following sources have been searched for evidence published in the previous six months

Some key Nursing journals were also scanned. For a full list of sources used for the update,  Please contact the Editor for further information.

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