Unnecessary return visits to the emergency department are a problem for most healthcare facilities face across Florida and other states. Unnecessary return visits are indicators of poor care quality. Numerous studies have demonstrated emergency departments discharge procedures are a significant contributor to unnecessary return visits (Taylor, 2000).
This issue creates gabs in continuity of care for patients resulting in an inadequate or incomplete emergency department discharge. The healthcare providers must realize that inadequate discharge negatively impacts patient compliance with care, treatments and follow-ups.
Providing verbal and pre-formatted written discharge instructions to the patient does not guarantee that the patient understands information provided. The patient must understand the medical information given and participates in their care. The best way to achieve patient understanding is communicating, and reinforcing while acknowledging culture, belief and language barriers.
The purpose of this project is to implement a discharge tool that will help healthcare providers to better communicate with patients and better achieve patient understanding.
The proposed intervention is to implement a discharge checklist tool that enables patients to document their understanding of discharge instructions by marking and answering questions about the discharge instructions packet. The patient and the provider will document the exchange by both signing the discharge tool. The tool will remain in the patient’s medical records.
After educating doctors, mid-levels providers and nurses on how to utilize the discharge tool they should be able to provide patients higher quality discharge instructions.
Most importantly, once individuals have been educated on the appropriate way to discharge an ED patient, it can be assumed these patients will continue to seek care accordingly. The implementation of this tool is expected to achieve the following outcomes.
Negative outcomes can occur with the implementation of the discharge tool. The providers will need to take time to explain and make sure the patient understands discharge material. This can cause a delay in discharges that will lead to an increase in discharge time. The issue can be resolved by delegating certain discharge topics between doctors and nurses.
For example, the doctors will discuss diagnosis, test results and treatments with the patient, while nurses will discuss treatment side effects, follow-up care and reinforce all material given.
Although hospitals have been striving to cut the cost, this goal has not been satisfactorily addressed because of the problem of unnecessary return visits to the ED. Most hospitals in the state of Florida have been concentrating on reducing 30-day readmission with a few activities and intercessions (Centers for Disease Control and Prevention, 2017).
In Florida, it is estimated that 28% of the acute care visits and half of the hospital admissions emerge from the ED (Center for Disease Control and Prevention, 2017). The authorization of Patient Protection and Affordable Care Act 2010 has shown the requirement for coordinating patient care voice in structuring the conveyance of social insurance (Rising et al., 2014).
The clarifications for patients to come back to the ED, the possibility of future return, and the recurrent unnecessary return visits can be obtained from administrative data. Some common factors have been associated with high rates of readmission of patients to ED.
They include low follow up care and any language barrier that limits patients from understanding the discharge instructions. Other variables include old age, non-ambulatory status, and absence of family support.
These visits are not only cumbersome to the healthcare personnel, but also an important indicator of the quality of care. The EDs constantly face the issue of limited resources, high rates of patient admissions, aging population, and deficiency of human services suppliers.
Majority of the ED have gotten amazingly overcrowded leading to long delays in care which contributes negatively to the patients’ outcomes since they cannot be treated on time. Patients returning to the emergency department have medical issues that have either failed to go away or improve or have gotten worse.
Being an important metric to measure the quality of healthcare, the problem of unnecessary return visits to the ED is very important to healthcare providers since it provides with essential information regarding their performance.
A reduction in the rate of unnecessary return visits to the ED is a marker of high-quality care, while an increase in the rate signifies poor healthcare performance and poor patient outcomes.
Advanced Practice Relationship
The nurse practitioners possess a deep level of knowledge in health care that allows managing a broad spectrum of clinical problems that ends with positive outcomes. Nurses assume a key role in transforming care.
They can offer cross cultural competencies and proficiency in care that leads to clear clarifications concerning patient discharge which involve the factors that emerge while patient is at home, and how to move toward circumstances that may force them to return to the ED (Rafnsson & Gunnarsdottir, 2010).
This will help keep the patients from heading off to the ED once more. Moreover, nurse practitioner’s relationship with patients is built on working together to achieve a positive outcome which helps with care compliances.
Nurse practitioners are proven to decrease patients ED visits, hospital admissions, and healthcare cost (Rushforth, 2015). The nurse practitioner can provide training that points towards upgrading the nurses and doctor roles that incorporates patient engagement.
This DNP Project is supported by the eight DNP Essentials. The essential I am the scientific underpinnings of this education which reflect the complexity of practice at the doctoral level and the rich heritage that is the conceptual foundation of nursing (AACN, 2006).
The educational part of this project will assist healthcare providers to understand the patterning of human behavior in interaction with the environment in normal life events and critical life situations after being discharge from the ED.
This will help improve science discipline by understanding the nature and significance of health and health care delivery phenomena. This essential also maintains that the extensive understanding of the nursing theory ensures that advanced nursing practice is built upon a solid foundation.
Graduates can therefore integrate nursing practice with organizational or analytical sciences (AACN, 2006). These science-based concepts can therefore be used to improve the quality of healthcare.
Essential II is the organizational and systems leadership to improve quality and systems thinking meaning that doctoral level knowledge and skills in these areas are consistent with nursing and health care goals to eliminate health disparities and to promote patient safety and excellence in practice (AACN, 2006).
This essential helps in transforming research into practice. The project is based on quality improvement by making changes to current discharge policies by providing the best practice to discharge a patient. This will improve patient outcomes after being out of the ED and prevent them from returning because they didn’t understand discharge/after care instructions.
Essential III states scholarship and research are the hallmarks of doctoral education (AACN, 2006). This essential mainly focuses on the complex issues that face modern health.
It further focuses on the medical dilemmas that physicians face in patient care, as well as shaping the evidence-based initiatives in the agenda of healthcare. The project uses analytic methods to critically appraise existing policies and other evidence to determine and implement the best practice to discharge a patient from the ED.
Essential IV allows the DNP prepared nurse to design by selecting, utilizing, and evaluating the programs that monitors outcomes of care, care system, and quality improvement including consumer use of health care information system (AACN, 2006).
This project contains a significant analysis that involved patient’s quality of care and the utilization of patient care technology. Findings represent an opportunity to evaluate the return visits to ED for inappropriate discharge.
Essential V refers to engagement with the policy development by identifying the problem and creating a healthcare system that meets the needs (AACN, 2006). This project helps the DNP prepared nurse to educate others such as policy makers regarding patient outcomes, policy change, and the correct way of discharging a patient from the ED. Additionally, would address and facilitate health care needs in acute care setting.
Essential VI states the importance of effective communication and collaborative skills in the development and implementation of practice models (AANC, 2006). The project demonstrates a collegiality within the community of knowledgeable people from different professions in health care system with endeavors to serve the population by utilizing healthcare resources.
Essential VII DNP prepared nurses is expected to evaluate care delivery models and the utilization of using concepts related to community, environment and occupational health, and cultural and socioeconomic dimensions of health (AACN, 2006).
The project embraces the community to the extent of knowledge by supporting strategies directed to improve all dimensions of health. Additionally, supports the theoretical framework that is utilized to guide the project in the community as a whole.
Essential VIII the DNP prepared nurse is expected to design, implement, and evaluate therapeutic interventions based on nursing science and other sciences (AACN, 2006). This project focuses on the established strengths and knowledge of the NP by applying them to the ability of the researcher of effectively evaluate, teach and educate individuals on the correct alternative provision of health care. This Essential shows DNP prepared nurse ability to demonstrate advanced levels of clinical judgment such as systems thinking, accountability in designing, evaluating evidence-based care to improve patient outcomes.
Population and Setting
Florida’s Celebration community is populous, which makes it an ideal area to create and execute the intervention. The population for this DNP Project is located in an acute care hospital in rural Central Florida.
They have varying cultural backgrounds, which are mainly determined by race. Local residents can be categorized into whites, African American, Hispanic, Asians, Native Americans, and people with a combination of two races. The culture of the target population impacts their health, beliefs about diseases and death, lifestyles as well as health promotion.
The psychosocial dimensions include can be categorized into three. Medical dimensions relate to the type of treatment, the perception of suffering, and the clinical course.
Psychological factors cover the disruption of life goals and the potential of adjusting life plans using coping strategies and emotional stability. The social factors comprise the availability of support from close associates such as friends, family, and co-workers.
Project Alignment with Practice Site Mission and Goals
The practice site for this project is a standalone emergency department in Polk County in the state of Florida. The facility is currently open twenty-four hour daily and staffed with healthcare professionals such as physicians, mid-levels providers, registered nurses and paramedics.
Its mission and goals are closely aligned with the project objectives which include providing high quality care to patients, ensuring patient compliance with discharge instructions and patient satisfaction. Other goal aligned with project is safe transitions of care, that is essential in promoting better patient experiences, reducing costs, and enhancing the quality of outcomes.
Unscheduled return visits to the emergency department reflects inadequate follow-up procedures or discharge practices. The goal of the project site is to eliminate indicators of poor-quality patient care and ensure that the facility enhances its provision of high-quality care by providing sufficient resources to the patients for them to be compliant with their care.
The environmental factors for the target population are significant in influencing the quality of their health and defining the necessary preventive measures. It is estimated that 23% of all deaths in the world, as well as 26% of deaths in children below the age of 5, are contributed by environmental factors that can be prevented (Healthy People 2020, 2019).
Some of the factors that impact the target population include climate change, exposure to toxins in food, water, air and soil, the contamination of their habitats, and occupational dangers.
The estimated demographic descriptors of the population are 49.1% male and 50.9% female and a median age of 35 for both genders. The population has an average family size of 3.14. The health literacy of the target population varies significantly according to race. For example, 14% of the whites are proficiency in health literacy; the rate literacy rate for Hispanics is 4%, with that of the African American being only 2% (Rikard et al., 2016).
The intermediate literacy rate for the three races is 58%, 31%, and 41 %, respectively. The proficiency level implies that individuals can clear read, write, understand, and solve problems. The intermediate level suggests that people can experience a problem, such as solving problems. Health literacy has direct impacts on health outcomes.
Literate people have better outcomes than illiterate ones. In 2016, the life expectancy of the target population was 78.8 (Rikard et al., 2016). Diabetes and stroke caused 21.3 and 37.6% of all deaths in this population. The adults that smoke cigarette makes 15.1% of the entire population. It is further estimated that 21.8% of the people visit the emergency room at least once a year.
The key stakeholders in this project are the physicians, nurses, home care providers, managers, and prehospital care personnel, as well as the insurance companies who pay for the patients’ medical care. The emergency department stakeholders primarily focus on the several indicators focus mainly on their capacity to provide quality care.
For emergency departments to effectively respond to patient care needs, the stakeholders must step in to ensure the current environment of health care delivery, enabling the ED to adjust changing models of care delivery; hence creating a controlled process that enhances the achievement of goals and efficiencies of the healthcare facility.
Benefit of Project
The major benefits of this project to clinical practice are to ensures improvement of the quality of care, patient satisfaction, discharge process and follow-up care, as well as significantly reducing the overall cost of patient care.
According to Lee et al (2015) a study done by Dr. Sabbatini and colleagues, it was determined that patients who unnecessary return to ED for further treatment have longer lengths of stay and increased costs during the repeat hospital admissions compared to those who do not return to the emergency department.
A greater understanding of the essentials of this project will be beneficial to physicians, nurses and other healthcare practitioners and improve their clinical practice; hence enhancing the overall patient care and outcomes, preventing unnecessary return visits to the emergency department.
The purpose of this project is the implementation of a clinical intervention to ensure a reduction of unnecessary return visits to the emergency department. The problem is the healthcare providers are not providing high quality of discharge instructions to patients and it reflects as a poor quality of care.
The findings in this project indicates that patients are returning to the ED unnecessarily due to the lack of resources provided by health care providers upon discharge. These providers are not explaining diagnosis entirely, treatment options, side effects and follow-up care resources to patients.
On the other hand, many patients do not understand medical terminology and further education such as reinforcing is needed, others are language barrier issue because translation takes a lot of time.
Many healthcare providers in the ED are in a fast pace and time is not enough for explanations which have led to poor quality of care. The issue is causing patients to return to ED due to poor outcomes in patient care. At the moment, it is evident several challenges are making it possible for many healthcare facilities to realize increased cases of unnecessary return visits.
The purpose of this project is to addressed these issues by training healthcare providers on appropriate ways to discharge patients and also the implementation of a discharge checklist tool that will ensure that patients receive discharge instructions in their preferred language with all resources needed well explained in simple vocabulary to help patient to understand after care plan or treatments.
This project will improve the quality of care and will reduce unnecessary return visits to the emergency department.
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