Nursing News

Project RED: Nurse Discharge Advocates Reduce Readmissions

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By Debra Wood, RN, contributor

Nearly one in five patients admitted to the hospital experience complications from a post-discharge adverse event, oftentimes leading to a readmission. Boston University’s Project Re-Engineered Discharge (RED), in which nurse discharge advocates develop a discharge plan and review it with patients, decreased the rate of readmissions by 30 percent and costs by 34 percent. 
Boston University researchers obtained $7.5 million in funding from the Agency for Healthcare Research and Quality and the National Heart, Lung and Blood Institute at the National Institutes of Health. The team studied existing discharge practices and developed 11 components of Project RED, such as educating the patient throughout the hospital stay and organizing post-discharge services. The National Quality Forum has endorsed the Project RED’s elements.
The team enrolled 749 adult patients in a clinical trial evaluating Project RED, with 370 randomized to the intervention arm. A nurse discharge advocate, not the patient’s regular nurse, worked with those patients, starting on the day of admission.
“Starting the discharge process on admission is key,” said Lynn Schipelliti, RN, one of the project’s discharge advocates. “They are going home a lot sicker and have a lot more to manage.”
The nurses arranged follow-up appointments, reconciled medications and educated patients about their conditions, their medications and self-care strategies, using an individualized instruction booklet. The patient’s primary care provider also received a copy of the booklet.
Schipelliti felt the ability to give the patient her undivided attention while addressing questions and troubleshooting anything that might happen when the patient goes home contributed to the program’s success. Then she would go back the next day, repeat the most important aspects and answer new questions.
“We would meet with them every day, gather information and identify key needs and hone in on those areas where the patient needed the most amount of help,” said Schipelliti, who expressed that she enjoyed the role. “When you see someone get something, it’s great. They appreciate that one-on-one time.”
Schipelliti said staff nurses also liked the intervention and that their patients were going home a little bit safer and more knowledgeable. 
A clinical pharmacist called patients two to four days post-discharge to reinforce the plan and answer questions about medications. 
The 11-component RED intervention saved $150,000, averaging $412 for each patient who received the intervention. However, those numbers do not include the cost of the intervention.
“It’s essentially one hour of nursing time for each discharge,” said Julie O’Donnell, project director for Project RED.
Project RED offers its tools and nurse training manual free at its Web site. More than 500 hospitals in nine countries have downloaded the materials.
Now the Project RED team has developed a virtual patient advocate, an electronic bedside patient education system, which takes over much of the teaching responsibilities. That would allow nurse advocates to work with more patients. The team is now studying the effectiveness of using the electronic program.
With the virtual system, the nurse discharge advocates develop the discharge plan. The patient responds to questions by touching the screen. At the end of the session, it prints out a list of questions the computer couldn’t answer for the nurse to address. 
“It’s not taking the place of nurses,” O’Donnell said. “It’s to free up some of their time.”
Patients have responded well. They can ask the same questions over and over without feeling embarrassed or that they are inconveniencing the nurse. Family members can interact with the computer program as well.
“We’ve had good feedback,” O’Donnell said. “Patients like it.”

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