NURSE-LED PATIENT EDUCATION, READMISSION REDUCTION 1 NURSE-LED PATIENT EDUCATION, READMISSION REDUCTION 2

NURSE-LED PATIENT EDUCATION, READMISSION REDUCTION 1

NURSE-LED PATIENT EDUCATION, READMISSION REDUCTION 2

Nurse-Led Patient Education to Reduce Hospital Readmission: A DNP Introduction

Doctor of Nursing Practice Project

Presented to the Faculty of Sinclair School of Nursing Graduate Studies
University of Missouri

_______________________________________________

In Partial Fulfillment
of the Requirements for the Degree Doctor of Nursing Practice
by
Morteza Amini, IMG, FNP, MSN, EMBA

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Introduction

Background

A Pervasive Burden of the Healthcare System

Hospital readmissions constitute a pervasive problem in the healthcare system of most countries around the world, “a wicked problem for leaders” (Feo et al., 2023, p. 1031). For years past and unknown, this challenge to political and administrative leadership refused to be managed and resolved. Consequently, these readmissions add more heavy loads to the healthcare system, which is already carrying the burdens of an aging population, high patient expectations, and increased technology use (Teo et al., 2023), including the use of artificial intelligence (Ram et al., 2023). These developments indicate that the complex situation that refused to be resolved appears to increase in complexity and resistance to any long-term, much less short-term, resolution. Meanwhile, the healthcare system must improve healthcare quality while restricting costs to the minimum possible, which is a major roadblock to leaders around the world (Pastorino et al., 2019).

A Potential Development of a Vicious Cycle of Poor Healthcare Quality

Joynt and Jha (2013) estimated that 66.7% of hospitals, which was equivalent to 2189 hospitals, in the United States would receive reduced payments from CMS. Lachar et al. (2023) implied that the long-term consequences of reduced payments to hospitals would involve a worsening of their already-high readmission performance. Most likely, these hospitals were non-teaching, smaller, and safety-net hospitals, which predominantly served the poor (Joynt & Jha, 2013). Therefore, high hospital readmissions can introduce to hospitals a vicious cycle from which they might never get out, resulting in worsening rates of readmissions.

Negative Impacts on Hospitals and Patients

Zhong et al. (2023) reported that 30-day hospital readmission could increase hospitalization costs by 47.9%, longer hospital stays, higher risk for death, and lower patient satisfaction. This problem reflects the inadequacies of a national healthcare system in addressing public health problems at lower costs to taxpayers (Ram et al., 2023). Therefore, hospital readmission reduces patient care quality and increases the costs of medical care (Teo et al., 2021).

Rationale

Hospital Readmission Is Hospital Accountability

The 30-day readmission rate is a common performance metric that hospitals utilize in estimating their competence in treating their patients with effective finality (Zhong et al., 2023). However, readmission literature has used other assessment periods, like 90 days and 365 days (one year) (Sana et al., 2023; Okafor et al., 2023). Regardless, failure in any of these metrics implies the ineffectiveness of a hospital’s therapeutic capabilities (Ram et al., 2023). Therefore, hospital ineffectiveness is hospital accountability.

Hospital Readmission Is Partly a Nursing Accountability

By extension, hospital readmission also reflects the competency of its nursing team to provide its patients with high-quality care at the lowest cost possible (Faessler et al., 2023). This accountability is more acute in organizations that employ nurses to replace physicians to reduce the cost of service (Meddings et al., 2023). Regardless, in either organization, nurses continued to dominate in the scope of care they provide to all patients admitted (Faessler et al., 2023). Therefore, hospital readmission confronts nurses with their limitations and incompetencies in theory and practice.

The Dominant Role of Nursing in Patient Care

Some studies indicated that better quality of patient care had been observed in healthcare facilities where the population of nurses dominated those of physicians. Meddings et al. (2023) reported patients who received most of their evaluation and management from a nurse practitioner had lower risks for unplanned hospital readmissions than those who did not. Al-Sabei and Ross (2023) noted that nursing leadership and the way it was exercised significantly influenced the reduction of hospital readmission rates. Therefore, nurse-led interventions to reduce, if not eliminate, hospital readmissions offered a strong potential for success in the future (Faessler et al., 2023; Zhong et al., 2023).

Problem Statement

A Broad Context and the Limitation of an Intervention Project

The broad range of impacted patients based alone on age expressed the overwhelming problem that hospital readmissions brought to the practice of nursing in any country (Alsaif et al., 2023; Remm et al., 2023). For instance, gastrointestinal and respiratory tract problems predominated the emergency pediatric readmissions in Riyadh (Alsaif et al., 2023). Meanwhile, elderly patients admitted to acute wards in Sydney, Australia, have a diverse range of conditions (Remm, 2023). Consequently, the context of designing interventions to address the problem of high hospital readmissions must be restricted to known high-readmission diseases in four bodily systems – cardiovascular, respiratory, skeletal, and urinary systems.

System-Categorized Diseases with the Largest Hospital Readmission Rates

Current and past data noted some consistency of high readmission rates in four system-categorized diseases: cardiovascular, respiratory, skeletal, and urinary systems. The Medicare fee-for-service data between April 2019 and September 2020 focused on two disease categories: cardiovascular diseases (acute myocardial infarction [AMI] and heart failure [HF]) and pulmonary diseases (chronic obstructive pulmonary diseases [COPD] and pneumonia) (CMS, 2022). As early as 2010, the Agency for Healthcare Research and Quality reported high readmission cases for congestive HF (n = 209,017; 24.7%), pneumonia (n = 477,894; 15.7%), COPD (n = 126,443; 20.9%), AMI (n = 85,932; 16.5%), and acute (and unspecified) renal failure (n = 70,756; 21.7%), and osteoarthritis (n = 42,241; 4.8%) (Elixhauser & Steiner, 2013), which is associated with total arthroplasty of the hip (THA) and the knee (TKA).

Meanwhile, Wang and Zhu (2022) noted a similar concentration of hospital readmissions to diseases under the two categories – COPD (6.99%), stroke or AMI (2.45%), and pneumonia (1.83%). However, two of the three diseases with the highest readmission rates were less precisely identified, namely, heart disease (8.09%) and nephritis-nephrosis (7.02%). Unfortunately, current and past studies tended not to simultaneously investigate all severe diseases in the form of system-categorized diseases. Consequently, this DNP Project can fill this gap in the research literature as a focus of interest for a nurse-led intervention in a hospital setting.

Current Hospital Readmission Rates of Select Severe Diseases

AMI

A dataset covering five years (2008-2012) across 103 hospitals in the United States found a readmission rate of 30.8% for AMI in adults (age, 18-55 years) (Okafor et al., 2023). It defined “all-cause readmission” as staying in any hospital for more than 24 hours within one year after discharge. Most patients readmitted were Black women (42.1%). However, a longer dataset period (2010-2019) under the National Readmissions Database with shorter observation periods showed a declining trend. Sana et al. (2023) observed a significant decline in the 30-day all-cause hospital readmission rates for AMI from 12.8% to 11.6%. Meanwhile, the 90-day all-cause readmission rates for AMI also declined from 20.6% to 18.8%.

Therefore, based on the most recent data, which was 2019, the 30-day readmission rate for AMI was 11.6% and 18.8% for the 90-day readmission rate. The longer five-year readmission rate was 30.8%. In effect, while the long-term hospital readmission rate appeared high, short-term hospital readmission rates showed lower levels but an increasing trend.

Coronary Artery Bypass Grafting

Dimagli et al. (2023) observed a hospital readmission rate of 8.5% for cardiac patients undergoing coronary artery bypass grafting (CABG) surgery at five years. The rate was 3.56 times lower than the all-cause readmission rate (29.4%) during the period. In a European study, Dinic et al. (2022) observed a 30-day hospital readmission rate of 11.2% to 15.6%. The most common cause of readmissions was in-hospital infections of the surgical site.

Therefore, based on the most recent data, which is 2022 and 2023, the 30-day hospital readmission rate for patients with CABG was 15.6%. Meanwhile, the longer five-year hospital readmission rate was lower at 8.5%. In effect, more recent hospital readmission rates appeared slightly higher than earlier hospital readmission rates, although long-term hospital readmission rates were almost halfway lower than short-term hospital readmission rates.

COPD

In UK studies published in 2019 and earlier, Alqahtani et al. (2020) found readmission rates of 8.8-26.0% for COPD at 30 days and 17.5-39.0% at 90 days. An earlier dataset (2006-2010) showed readmission rates of 10.2% at 30 days and 17.8% at 90 days (Harries et al., 2017). Meanwhile, a United States dataset (2006-2015) found a 30-day readmission rate of 7.10-7.76% for COPD at baseline in 2006, followed by a slight decline of 0.52% in 2010 (Myers et al., 2020).

Therefore, based on the most recent data, which is 2019, the 30-day hospital readmission rate for COPD was 26.0%. Meanwhile, the 90-day hospital readmission rate was higher at 39.0%. In effect, more recent hospital readmission rates for COPD appeared higher than earlier hospital readmission rates.

End-Stage Renal Disease

The hospital readmission profile of patients with end-stage renal disease (ESRD) is complicated. It is often associated with other conditions that directly cause readmission. Using the 2017-2018 National Readmissions Database, Park et al. (2022) noted a higher all-cause readmission rate of 34.4% (vs. 19.2% without transcatheter aortic valve replacement [TAVR]) for patients with ESRD and TAVR and also a higher cardiovascular readmission rate of 13.2% (vs. 7.7% without TAVR) at 90 days. Meanwhile, Sawalha et al. (2021) noted a higher hospital readmission rate of 17.8% for patients with ESRD at 30 days (vs. 10.4% in non-CKD patients) and 41.2% at 90 days (vs. 21.0% in non-CKD patients).

HF

Like ESRD, HF is often a secondary diagnosis to primary conditions, like AHI or pneumonia, which implies a complex confluence of factors associated with observed hospital admission rates. Using the 2008-2015 dataset for patients covered by Medicare, Blecker et al. (2019) observed that primarily diagnosed HF had an eight-year hospital readmission rate of 26.1%, which was slightly higher levels than those diagnosed secondary to AMI (24.9%) and pneumonia (24.4%). Meanwhile, Foroutan et al. (2023), which studied uncomplicated HF, observed a 30-day hospital readmission rate of 13.2% and a one-year hospital readmission rate of 35.7%. However, Middle Eastern HF patients showed far lower hospital readmission rates in the 30-day (4.47%) and 90-day (8.35%) periods (Lick & Mulhem, 2023).

Pneumonia

Lawrence et al. (2023) observed a 30-day hospital readmission rate of 39.6% (vs. 21.8% for other respiratory disorders) for patients with pneumonia in the United Kingdom. Using 2017 data from the U.S. Nationwide Readmission Database, Amritphale et al. (2023) reported a 30-day hospital readmission rate of 10.5% for patients with pneumonia. Therefore, the readmission rates appeared to vary between countries and between observation periods.

THA

Like ESRD, THA has been associated with other conditions, especially renal dialysis and ESRD, perhaps due to the kidney-damaging pain management involved in conditions that require total arthroplasty. Malkani et al. (2020) observed a hospital readmission rate of 30% for nonrenal patients with THA at 90 days. However, hospital readmission rates were higher in patients with chronic kidney disease (CKD): under dialysis (55%) and post-kidney transplant (43%). Meanwhile, using the 2011-2018 dataset of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), Metoxen et al. (2023) found a declining eight-year trend from 2011 (4.5%) to 2018 (3.3%) for combined total hip and knee arthroplasties. Hospital readmissions resulted from higher levels of medical (52.6%) and surgical (37.7%) complications. Medical complications included diseases of the circulatory and digestive systems. Meanwhile, surgical complications included site infection, wound disruption, and venous thromboembolism.

TKA

Using the ACS-NSQIP data, Metoxen et al. (2023) observed the same combined hospital readmission rates with HKA, which showed a slightly declining trend from 4.5% to 3.3%. These readmission rates came from lower medical complications (38.5%) but higher surgical complications (50.7%). The findings on hospital readmissions on TKA appeared consistent with the findings of Sarpong et al. (2019) at 30 days over six years (2010-2013 to 2014-2016), although at slightly lower levels of 3.63% to 3.23%. In effect, based on recent data, the hospital readmission rates in short and long observation periods appeared to be low at less than 4.00%.

Intervention by Nurse-Led Patient Education

The DNP Project proposed the use of nursing education as the key intervention in a hospital’s Readmission Reduction Program. As early as 2014, Hume and Tomsik (2014) argued for patient education as a critical strategy for reducing hospital readmission rates. Moreover, failure to perform a nurse-led patient education supposedly contributed to “the revolving door effect of patients discharging from and re-entering hospitals” (Hume & Tomsik, 2014, p. 112).

Considering the chronic nature of the selected system-based diseases strongly associated with hospital readmission rates despite the acute manifestations of some of these diseases, patient education must focus on these chronic diseases. Literature involved patient education on chronic diseases, such as COPD (Collinsworth et al., 2018), and acute conditions, like HF (Oh et al., 2023; Laal et al., 2017).

More importantly, patient education on chronic conditions has been found effective. Collinsworth et al. (2018) found a COPD-designed patient education program, which was a chronic disease readmission reduction program, effective in reducing hospital readmissions both in COPD cases and all-cause hospital readmissions. The teach-back method of implementing the patient education intervention demonstrated significant effectiveness in reducing overall hospital readmission rates for patients with HF (Oh et al., 2023). Rice et al. (2018) confirmed the contribution of nurse-led patient education in reducing hospital readmissions for patients with HF.

Objectives

This DNP Program intends to pursue two program objectives:

Program Objective: To reduce the 30-day readmission rate for the specified cardiovascular, respiratory, skeletal, and urinary diseases by 20%.

Process Objective: To increase nurses’ participation in the nurse-led patient education program for hospital readmission reduction by 35% at 30 days.

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