Discharge Protocols and Preventing Readmission

The high rate of readmissions after the previous discharge of adult patients is an urgent issue, as the existing ineffective protocols may lead to financial burdens or lethal consequences. Thus, there is a need to identify and eliminate the possible causes. The practically proved solutions to avoiding the readmissions are post-discharge interventions and constant support within the following 48 hours, encouraging self-care, and extending the methods of such assistance.

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Change Model Overview

The Evidence-Based Practice is an effective method of exploring issues and searching interventions in nursing practice. The ACE Star model is a framework designed to facilitate the process of transforming the solutions found from EBP into the action. The Star model is represented by five stages of implementing the nursing discoveries. The framework should be used by nurses due to its structural simplicity, as it provides the time-saving effective research and analysis process, which thus facilitates the implementation of crucial changes in healthcare system.

Defining the Scope of the EBP

The existing protocols and the lack of post-discharge support cause readmissions among adult patients ages 50 and above, related financial burdens, and time-consuming procedures, and need to be revised. The scope of the project issue covers the procedures of risk assessment for discharging the patients and the following support within 48 hours after discharge and the 30 days readmission rate. The researches show the issue is urgent nationwide and prove that the interventions and the post-discharging assistance of these patients can reduce the period of hospital stay and reduce readmissions. Therefore, this clinical issue is of concern as the rate of readmission should be reduced. This is done effectively with proper a discharge process and follow-up guidelines.


The stakeholders chosen for the project are practitioners dealing with the elderly, the patients, the investors, and the nurse leaders. The team consists of the following members: a general nurse practitioner, a critical care nurse, and a health policy nurse.

Determining Responsibility of Team Members

The above-mentioned members of the group are nurses who can provide an insight and are competent within their responsibilities. The general NP analyses the data and provides a professional opinion on the issue. The critical nurse assists with the evaluation of the urgent critical cases after readmission. The health policy nurse aids collecting and analyzing the research data. All of the members collaborate to search the ways of implementing the project.


Within the project, the team addressed several investigating approaches to find supporting evidence on the issue. Several types of research demonstrate that, while the poor post-discharge patient treatment or its absence often causes the following readmissions, the discharge interventions prevent unexpected hospital visits after the discharge. At the same time, the studies showed that avoiding readmission requires post-discharge care and comprehension of the reasons for the readmission. The studies are reliable, as they referred a wide time range, were based on reliable healthcare literature and examined numerous databases.

Summarizing the Evidence

According to Leppin et al., the tested interventions in 42 trials proved to be effective, but the efficacy decreased through time, and hence the support should be complex (Leppin et al., 2014). Another study concludes that the post-discharge care can reduce a patient’s hospital time, decrease admittance of the facilities, and prevents lethal consequences (Francischetto, Damery, Davies, & Combes, 2016). The abroad research states that interventions effectively reduce emergency admissions in the UK (Wallace, Smith, Fahey, & Roland, 2016). The other study stresses on the financial drawbacks of the healthcare discoordination and finds a solution in the appropriate transition of care (Brown, 2018). Every study stresses on the importance of the post-discharge treatment and assistance.

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Developing Recommendations for Change Based on Evidence

Based on the research, the recommendations for countering the issue are giving consultations to the patients aged over 50 on the self-care, providing 48-hour support for the discharged elderly, and create a complex of preventive measures against the readmissions.


Action Plan

The plan for implementation should consist of complex readmission-preventive actions. To implement the innovation, firstly, the research results should be provided for nurses and practitioners through educational seminars. The practitioners should create statements, which the future reports on the results will be based upon. The next steps are generating an optimal post-discharge assistance framework which should include encouraging patients’ self-education, collecting data from the practitioners’ reports, examining the efficacy of the approach. The time needed for improvements is three months.

Process, Outcomes, Evaluation, and Reporting

The desired outcomes are decreasing of the registered readmissions and reducing patients’ extra expenses. The results are to be measured by the practitioners’ reports. The results will be structured as a presentation and will be shown to the key stakeholders at the board meeting.

Identifying Next Steps

On a larger scale, the plan needs more hospitals and institutions to involve and cooperate. The approach will be also applicable to the larger scales, as the data will be more concise. To enroll the innovations successfully, there is a need to share the achievements with the community and seek for the governmental support.

Disseminating Findings

Communicating the results within the organization will be held during the open meetings. The external spread will be conducted through publically available reports and the official website.


To conclude, the issue of the elderly being readmitted after the preceding discharge needs solving. The conducted research helped to discover the current data on the issue and the measures of countering the unexpected readmission. The studies showed the post-discharge interventions considerably decrease the further hospital attendance. The interventions, accompanied by further constant support, self-care encouraging, and extending the assistance methods, can solve the issue and save millions of lives.


Brown, M. M. (2018). Transitions of care. Chronic Illness Care, 4(1), 369-373.

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Francischetto, E. O., Damery, S., Davies, S., & Combes, G. (2016). Discharge interventions for older patients leaving hospital: Protocol for a systematic meta-review. Systematic Reviews, 5(1), 48.

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., &… Montori, V. M. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107. Web.

Wallace, E., Smith, S. M., Fahey, T., & Roland, M. (2016). Reducing emergency admissions through community based interventions. BMJ, 352. Web.

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