Key Words: Discharge; planning; teaching; individualised; outcomes; patient; readmission; length of stay; nursing; hospital
Does discharge planning improve the appropriate use of acute care?
Does discharge planning improve or (at least) have no adverse effect on patient outcomes?
Does discharge planning reduce overall costs of health care?
Discharge planning involves developing individualised discharge plans for patients before they leave the hospital, with the aim of improving the efficiency and quality of healthcare delivery. Nurses are ideally positioned to play an important role in the discharge planning of patients from hospital to home and should be knowledgeable about the impact of individualised discharge planning on patient outcomes.
This is a summary of a Cochrane review containing 24 randomized controlled trials (RCTs) involving 8,098 participants. All patients in hospital were eligible to participate regardless of age, gender, or health condition.
The intervention group received individualised discharge care which included an assessment, planning, implementation, and monitoring phase. Half of the trials included a discharge planning advocate who was a nurse. The control group received routine discharge care that was not tailored to the individual patient.
The outcomes of interest included length of stay in hospital, readmission rate to hospital, patient health status, patient satisfaction, and cost of discharge planning to the hospital.
The quality of the included studies was judged as moderate using the GRADE approach. Meta-analysis was undertaken where possible; otherwise, a narrative summary was provided.
Summary of Key Evidence:
A statistically significant reduction in length of stay in favour of the intervention group was found in the pooled results of 10 trials that recruited older patients with a medical condition (mean difference -0.91, 95% confidence intervals [CI] -1.55 to -0.27).
A statistically significant reduction in 3-month readmission rates in favour of the intervention group was also shown for elderly patients with a medical condition in the 12 trials that reported data on unscheduled readmission rates (Relative Risk [RR] 0.82, 95% CI 0.73 to 0.92).
Eleven trials measured the impact of discharge planning on patient outcomes, including functional status, mental well-being, and perception of health. One trial reported significantly more improvements in quality of life scores for the treatment group compared to the control group (mean difference 22.1 (20.8); P < 0.01); another trial reported statistically significant improvements in patient- reported health status for areas such as the mental aspects of social functioning (p=0.03) and vitality (p=0.004) in favour of the intervention group.
One out of four trials reporting satisfaction demonstrated significantly increased satisfaction for patients allocated to the individualised discharge planning group (P<0.05).
Seven RCTs evaluated the effect of discharge planning on overall health care costs and hospital care costs. Three of the four trials that reported on the effect of discharge planning on overall costs of health care reported significant reduced costs for patients in the intervention group versus control ($412 to $460 per person and 519 euros per person).
Best Practice Recommendations:
The current evidence suggests that a discharge plan tailored to the individual patient may bring about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition as well as positive effects of individualised discharge planning on patient health outcomes versus usual care. The impact of the intervention on reducing overall healthcare costs is uncertain given the limited evidence. Thus, it is unknown whether the intervention resulted in true cost savings or whether costs were merely shifted from secondary to primary care.
Diana An, RN, BScN, CRA, MSc candidate
Nursing Research Associate
Registered Nurses’ Association of Ontario (RNAO)
A member of the Cochrane Nursing Care Field (CNCF)
Shepperd S., Lannin N.A., Clemson L.M., McCluskey A., Cameron I.D., & Barras S.L. (2013). Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub4. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000313.pub4/full Nov 5, 2013