BACKGROUND An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs. OBJECTIVES To determine the relationship between home health agency work environments a...

INTRODUCTION Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains. CHALLENGES In this pape...

OBJECTIVE The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide card...

OBJECTIVES Difficulties with transition from inpatient to outpatient care can lead to suboptimal outcomes for patients. We implemented a protocol for systematic follow-up phone calls to families of pediatric patients after discharge, primarily to improve care transition. We also hypothesized that the phone calls would decrease readmissions and emergency department (ED) visits after discharge an...

INTRODUCTION To ensure continuity of care, it is important to effectively communicate the health status of older patients who are transferred between health care organizations. The objectives of this study were to: (1) evaluate the prevalence of nursing transfer documents, and (2) identify patient and transfer characteristics associated with the presence of nursing transfer documents for older ...

OBJECTIVES To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs. DESIGN AND SETTING Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs. PARTICIPANTS P...

Flinders Medical Centre was experiencing issues with timely discharge and knowing the potential discharges and in-patient bed capacity for the next day. This case study describes the application of 'visual management' theory to discharge processes. The solutions developed were 'patient journey boards' and 'discharge traffic lights'. The implementation of these visual management systems has enab...

Decreasing patient fall injuries during hospitalization continues to be a challenge at the bedside. Empowering patients to become active participants in their own fall prevention care could be a solution. In a previous study, elderly patients recently discharged from a United States hospital expressed a need for nurses to give and repeat directives about fall prevention; when the nurse left a b...