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Running head: PATIENT-CENTERED CARE
Patient-Centered Care
Your Name (without credentials)
November 2017
NOTE: No abstract
NOTE: This is a template and guide. Delete all yellow highlighted words.
Patient-Centered Care (paper title)
1
PATIENT-CENTERED CARE
2
(No heading of Introduction) Introduce your assigned paper topic. Type and properly cite
the definition of your topic in relation to professional nursing.
Patient-Centered Care in Professional Nursing (first main point)
Type statements about this first main point here. This paper should be based on facts
from Hood and the assigned article. Most of these facts should be paraphrased (including proper
citations). One or two direct quotations (with appropriate citations) can be used in this paper.
There should be no prior knowledge, experience, or opinion in this paper. All facts must be cited
to one of the two assigned sources.
Add paragraphs here as needed.
Discharge Planning Rounds Using Patient-Centered Care (second main point)
Type statements about this second main point here. This paper should be based on facts
from Hood and the assigned article. Most of these facts should be paraphrased (including proper
citations). One or two direct quotations (with appropriate citations) can be used in this paper.
There should be no prior knowledge, experience, or opinion in this paper. All facts must be cited
to one of the two assigned sources.
Add paragraphs here as needed.
Conclusion
Summarize the main ideas and major conclusions from the body of your paper. Do not
add new information in the conclusion.
PATIENT-CENTERED CARE
3
References (centered, not bold)
Type your references here alphabetized by the first author of each source using hanging indents
(under “Paragraph” on the Home toolbar ribbon). See your APA Manual and the
resources in the APA folder in Course Resources under Modules for reference
formatting.
Research for Practice
Discharge Planning Rounds to the
Bedside: A Patient- and FamilyCentered Approach
Diane M. Salentiny Wrobleski, M. Ellen Joswiak, Donna F. Dunn, Pamela M. Maxson, and
Diane E. Holland
he discharge planning (DP)
process requires clear communication and collaboration among multiple health care
team members, patients, and their
family members (Centers for
Medicare & Medicaid Services, 2013;
Institute for Healthcare Improvement [IHI], 2006; Institute of
Medicine Committee on Quality of
Health Care in America, 2001;
Institute of Medicine Committee on
the Work Environment for Nurses
and Patient Safety, 2004; University
Health System Consortium, 2006).
“Development of an effective discharge planning process places
patients and caregivers as the central
focus of care by engaging them along
with the healthcare professionals in
the whole discharge planning
process” (Yam et al., 2010, p. 10). A
patient-provider partnership that
allows the patient to identify his or
her needs and treatment goals,
choose treatment options, monitor
symptoms, and evaluate and revise
therapies will promote active patient
participation in the discharge planning team (Anthony & Hudson-Barr,
2004; Bauer, Fitzgerald, Haesler, &
Manfrin, 2009; Coleman & Williams,
2007).
T
Discharge planning rounds done at the bedside is an effective
patient-centered approach to discharge planning and does not
take any longer than traditional rounds apart from the patient and
caregiver. Bedside rounds may decrease patient utilization of health
care resources after discharge.
to the topic of discharge planning
rounds and the availability of family
at the patient’s bedside for discharge
discussions.
Despite the abundance of studies
in the literature related to discharge
planning, the adaptation of rounding for this process (held in a conference room or at the bedside) has
received minimal attention. Publications regarding discharge planning
rounds are older, fewer, and limited
to composition of team members,
frequency of rounds, and their contribution to continuity of care
(Chakrabarty, Beallor, & Pelle, 1988;
O’Hare, 1992; O’Hare & Terry, 1988;
Shardien, 1997; Zwicker & Picariello,
2003). No studies were found that
evaluated the feasibility and effectiveness of bedside discharge planning rounds compared to rounds
held by the health care team in a
conference room without patient
and family present. Although multidisciplinary rounds have become a
tool for multiple health care team
members to discern patient needs
upon discharge, engagement of
patient/family participants in the
process has been understudied
(Nosbusch, Weiss, & Bobay, 2010).
Clark, Dodge, Partridge, and
Martinez (2009) conducted a literature review of all aspects of interventions needed for people living with
chronic obstructive pulmonary disease (COPD), identifying interven-
Diane M. Salentiny Wrobleski, PhD, RN, ACNS-BC, RN-BC, is Nursing Education Specialist, and
Assistant Professor of Nursing, College of Medicine, Mayo Clinic, Rochester, MN.
M. Ellen Joswiak, MA, RN RN-BC, is Nursing Education Specialist, Department of Nursing, and
Instructor in Nursing, College of Medicine, Mayo Clinic, Rochester, MN.
Donna F. Dunn, BSN, RN, CMSRN, is Instructor of Nursing, College of Medicine, Mayo Clinic,
Rochester, MN.
Literature Review
A literature search was done using
CINAHL and Medline for articles
pertaining to discharge planning
rounds. Terms used in the search
were hospital discharge planning, discharge planning rounds, and patientcentered care. Results were limited to
English language journals published
from 2001 to 2013. Abstracts were
reviewed and selected for pertinence
Pamela M. Maxson, PhD, RN, CNS, is Nurse Manager, Admission/Outpatient Surgery, Department
of Nursing, Mayo Clinic, Rochester, MN.
Diane E. Holland, PhD, RN, is Clinical Nurse Researcher, Department of Nursing, and Associate
Professor, College of Medicine, Mayo Clinic, Rochester, MN.
Acknowledgments: This study was funded by the Nursing Research and Evaluation Committee,
Department of Nursing, Mayo Clinic. The authors wish to thank Joel Pacyna for his review of the manuscript relative to clarity, organization, grammar, and content; and Stacey Talabis, BNS, RN, for data
collection.
Role of the Funding Source: The funding source had no role in the design and conduct of the study;
collection, management, analysis, and interpretation of the data; or preparation, review, and approval
of the manuscript.
March-April 2014 • Vol. 23/No. 2
111
Research for Practice
Background
In descriptions of discharge planning (DP) rounds found in the literature, rounding rarely is described. The purpose of this study was to compare time to complete
rounds and health service utilization after discharge between DP rounds held in a
conference room and those conducted at the bedside.
Methods
A prospective, cross-sectional survey study was conducted with 120 patients
admitted to one of three surgical units in a Midwest medical center. Time to complete rounds was recorded. Number of unplanned re-admissions, emergency
room visits, and calls to physicians were captured by phone interview after discharge.
Little recent literature addresses
discharge planning processes in pediatric or pediatric intensive care settings that advocate for family inclusion in multidisciplinary medical care
rounds (Kuo et al., 2012) The evidence related to other types of rounds
(e.g., medical care focused, nursing
change of shift) suggests patient
active participation in the process,
development of patient-centered
goals, and patient/family education
reduce health care cost and empower
patients (Anderson & Mangino, 2006;
Caruso, 2007; Trossman, 2009).
Results
No more time was needed to conduct rounds at the bedside than to hold rounds
in a conference room (p=0.80). Fewer re-admissions or emergency room visits
(p=0.047) and clarifying calls were made after discharge (p=0.04) in the group
with bedside rounds.
Conclusions
Moving DP rounds to the bedside with active participation by patients and family members is feasible and effective.
tions most associated with positive
outcomes. Interventions with a multidisciplinary team managed by
nurses seemed to most improve
health-related quality of life for persons with COPD while decreasing
unplanned re-admissions. Health
care costs also decreased, while survival rates increased in older adults
with chronic heart failure. A number
of mechanisms exist that facilitate
this patient/family-provider partnership and enhance communication
and collaboration among team
members in the DP care process.
One such mechanism is a discharge planning conference, in
which care providers, the patient,
and in some cases, his or her family
caregivers, participate in a face-toface discussion to map the plan for
transitioning the patient’s care to
another setting (Almborg, Ulander,
Thulin, & Berg, 2008; Carroll &
Dowling, 2007; Popejoy, 2011). This
type of conference is not held routinely for all patients, but generally is
reserved for patients with medically
complex plans that involve multiple
formal and informal services needed
upon discharge (Holland, Mistiaen,
& Bowles, 2011).
112
Another mechanism is discharge
planning rounds, which have
adapted the basic features of rounding that are found in multidisciplinary rounds. Multidisciplinary
rounding is the familiar process utilized for communicating patients’
daily plans of care. Providers from
different disciplines meet to communicate, coordinate patient care,
make joint decisions, and manage
responsibilities (Gurses & Xiao,
2006). Rounds can be held with or
without the patient and family
present. Multidisciplinary rounds
have different purposes (medical,
teaching, discharge planning),
occur at different times (morning,
after admission, change of shift),
and can be held in different locations (conference room or bedside).
Rounds occurring at the patient’s
bedside can increase patient safety
(Edwards, 2008) and patient satisfaction (Kalisch, McLaughlin, &
Waller Dabney, 2012; Tea, Ellison, &
Feghali, 2008). They have proven
effective for training (Cook &
Gutowsky, 2007) and for engaging
patients, and invaluable for improving communication (Castledine,
Grainger, & Close, 2005).
Purpose
The purpose of this study was
twofold. First, the study sought to
determine the feasibility of conducting DP rounds at the bedside by comparing time to conduct DP rounds at
the bedside and in the conference
room. Second, the study aimed to
identify differences in the quality of
DP rounds with respect to outcomes
by comparing the number of
unplanned hospital re-admissions,
emergency department (ED) visits,
and telephone calls by patients to
providers following DP rounds held
at the bedside (active patient/family
participation) with subsequent DP
rounds held in a conference room.
Conceptual Framework
A quality health outcomes framework guided the prospective, crosssectional survey study design
(Mitchell, Ferketich, & Jennings,
1998). This framework provides
organization for evaluating DP
rounds as a practice intervention.
This framework suggests system,
provider, patient, and family characteristics influence intervention outcomes. Characteristics understood to
influence DP outcomes include ineffective communication and unavailability of hospital or community
practitioners for consultation as the
discharge plan is arranged (Bowles,
Foust, & Naylor, 2003; Proctor &
Morrow-Howell, 1990). Structural elements such as the health care system’s DP process also influence outcomes (Mitchell et al., 1998).
March-April 2014 • Vol. 23/No. 2
Discharge Planning Rounds to the Bedside: A Patient- and Family-Centered Approach
Methods
The study setting was a large,
referral-based academic medical
center in the Midwest. After approval by the study site’s institutional review board, 120 patients were
invited to participate and consented
into the study early during their
hospitalization on one of three surgical units. Two units primarily
housed patients who had undergone colorectal and general surgical
procedures. Patients on the third
unit had undergone gynecologic
surgical procedures. While the units
had different nursing staff, managers, and clinical nurse specialists
(CNS), they shared the same discharge planning nurse (DPN) and
social worker (SW) who attended all
DP rounds on the three units.
Typically DP rounds were held in a
conference room with direct-care
nurses, the unit nurse manager,
CNS, DPN, and SW in attendance.
For the study, DP rounds continued to be held in a conference room
without patients and their family
members on one of the colorectal
and general surgery units. On the
other colorectal and general surgery
unit, DP rounds were held at the
bedside with patients and family
present. The gynecologic surgery
unit was divided geographically into
two distinct pods. DP rounds were
conducted for one pod in a conference room (patient/family absent).
On the other pod, rounds were held
at the bedside with active patient/
family participation. Three attempts
were made by telephone to contact
all patients beginning 7-10 days after
discharge. Patients were asked if they
had been re-admitted, had visited
the emergency department, or had
made any unplanned calls to their
physicians to clarify continuing care.
Bedside discharge planning
rounds were instituted following a
structured protocol (see Figure 1).
The DPN, SW, nurse manager, CNS,
and the patient’s direct-care nurse
entered the patient’s room and discussed the patient’s continuing care
needs, goals, and preferences for
care with the patient and family
caregivers. Whenever continuing
care needs were identified, plans to
FIGURE 1.
Discharge Rounds
1.
2.
3.
4.
5.
6.
Patient name, age, primary service, and surgical procedure
Predicted length of stay and predicted date of discharge
What was the patient’s admission baseline living arrangement? Were there any
equipment or resource use requirements before surgery (walker, oxygen,
wound care, home health care)?
If the patient came from a skilled nursing facility, was a phone call done within
24 hours to determine if the bed was held?
Where is the patient going after his or her hospital stay? If patient returning
home, who will assist him or her?
Discharge needs:
• Home health care offered as appropriate, and documented
• Equipment needed (oxygen, wound VAC, walker, etc.)
• Education needed (total parenteral nutrition, tube feeding, drains, dressings)
• Is the written nurse-to-nurse handoff communication up to date?
• Prescriptions written (oxygen, medications, wound VAC paperwork)
The goal is to have the patient ready for discharge the
day before the actual discharge date.
meet the needs were discussed with
direct input from the patient and
family.
The two main outcomes were
time to complete DP rounds and utilization of health care services after
hospital discharge. Time spent discussing each patient’s discharge
needs was recorded by a research
assistant during all rounds for both
the control and intervention groups.
In addition to the patient call 7-10
days after discharge, the patient’s
medical records were reviewed for
documentation of any events.
Demographic and health characteristics of the sample were collected
by medical record review using an
investigator-developed instrument.
Two measures were used to determine
if differences existed between the
groups in terms of severity of illness:
the American Society of Anesthesiologists (ASA) scores and the All
Patient Refined Diagnosis-Related
Groups Severity of Illness (APR DRG
SOI) scores. The ASA score is determined by a five-category physical status classification system used for
assessing the fitness of patients before
surgery (Walker, 2002). All participants were scored as 2 (a patient with
mild systemic disease) or 3 (a patient
with severe systemic disease). The
APR DRG SOI score is assigned based
on the patient’s specific diagnoses
March-April 2014 • Vol. 23/No. 2
plus procedures performed during his
or her hospital stay, and is used commonly to adjust for patient complexity (Wynn & Scott, 2007). Patients
with higher SOI are more likely to
consume greater health care resources
and have longer hospitalizations than
patients with lower SOI in the same
DRG.
Differences between groups (conference room and bedside DP rounds)
were analyzed using t-tests and chisquare tests for continuous and categorical variables respectively. Nonparametric tests were utilized if the
data were not distributed normally.
All data were analyzed using the
Statistical Package for Social Sciences
Version18 (SPSS, Inc., Cary, IN).
Results
Of the initial 120 study participants, 110 were contacted after discharge. Ten were lost to follow up
(six in the conference room group,
four in the bedside group). The average number of days after discharge
the research assistant was able to
reach participants by phone varied
from 16 days for the conference
room DP rounds group to almost 20
days for the bedside DP rounds
group. This difference in time to follow up was not statistically significant (p=0.07).
113
Research for Practice
Patients in the groups were similar in average age (p=0.19), sex representation (p=0.07), and racial mix
(p=0.41). No statistically significant
difference was found in ASA scores
(p=0.33) or APR DRG SOI scores
(p=0.67) between the groups. Patients in the two groups did not differ in number of referrals to postacute services (p=0.30), whether they
went home with an ostomy (p=0.66)
or a drain (p=0.82). See Table 1 for
group demographic and health characteristics.
A significant difference was found
in hospital length of stay between
groups (p=0.02). Patients in the conference room DP rounds group
stayed on average 8.0 days, while
patients whose DP rounds were held
at the bedside stayed on average 5.4
days, a difference of almost 3 days.
The only other notable difference
was more patients went home with
wound packing in the conference
room DP rounds group than in the
bedside DP rounds group (p=0.004).
The first outcome of interest was
time to complete DP rounds. Time
per patient spent in DP rounds did
not differ significantly between
groups (p=0.80). Discussions took on
average 1.42 minutes (SD=0.53) per
patient during rounds held in the
conference room and 1.47 minutes
(SD=0.39) per patient for rounds at
the bedside.
Utilization of health care resources after discharge is identified
in Table 2. Significant differences
existed between the groups. More
patients in the DP rounds group
needed to contact a physician or
other health care provider (p=0.047),
visited the ED, or experienced a hospital re-admission (p=0.04) because
of an unexpected complication.
TABLE 1.
Sample Demographic and Health Characteristics
Age
Usual DP
Rounds
n=60
Bedside DP
Rounds
n=60
Mean (SD)
Mean (SD)
p Value*
53.9 (17.8)
57.8 (14.6)
0.19
Mean Length of Stay
8.0
(7.6)
5.4
(4.4)
0.02
Patient Discussed in DP Round
3.0
(3.7)
2.5
(3.0)
0.47
Length of Time from DC to Call
16.0
(5.7)
19.9
(9.6)
0.07
N
(%)
N
(%)
Sex
Male
13 (21.7)
23 (38.3)
Female
47 (78.3)
37 (61.7)
Ethnicity
0.41
White
56 (93.3)
52 (86.7)
Non-White
1
(1.7)
1
(1.7)
Unknown
3
(5.0)
7 (11.7)
ASA Status
0.33
1
0
(0.0)
1
(1.8)
2
40 (72.7)
35 (63.6)
3
15 (27.3)
17 (30.9)
4
0
(0.0)
2
(1.8)
Severity Index (n=108)
0.67
1
12 (22.6)
17 (30.9)
2
24 (45.3)
25 (45.5)
3
14 (26.4)
10 (18.2)
4
3
Lives Alone
(5.7)
7 (11.7)
Referral to Post-Acute Care
3
(5.5)
3
(5.0)
0.32
19 (31.7)
13 (21.7)
0.30
14 (23.7)
12 (20.0)
0.66
8 (13.6)
9 (15.0)
0.82
1
0.004
Home with
Ostomy
Drain
Wound packing
11 (18.3)
(1.7)
Discussion
Notes: ASA status = The American Society of Anesthesiologists score;
APR DRG SOI = All Patient Refined Diagnosis-Related Groups Severity of Illness
In this study, DP rounds held at
the bedside were both feasible and
effective. They required no more time
per patient to complete. Fewer
patients who actively participated in
di …
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