Abstract

The study looks at the proposal of performing a viability study on initiating a designated discharge nurse education program at John Hopkins All Children’s Hospital in St Petersburg Florida.  In contemporary years the use of discharge education as a liberation remedy for children has grown and it is being considered for implementation in all health care facilities.  An analysis of the available literature on this topic mostly looks at the evidence that is accessible for the discharge nurse education program results, obstacles and the procedures for care.  to be able to effectively conduct this study several directorial and scientific investors will require to be involved to correctly strategize on the set-up sustenance that discharge nurse education program  would necessitate and astound monetary and administrative obstacles.  The study exploited for this research will be virtuously secondary, and tit will hence not need any approvals from the institutional review board (IRB).  It is however to note that this will be a very resource concentrated task, and the whole plan will require to take into special considerations, the needs of the patients as well as the whole concept of clinical experience. The potential sources that will be used to help in funding this innovation have been critically analysed to help understand the requirements and the expected amounts that can be granted. At the end of the study, the broadcasting of discoveries are deliberated with enticement to present the outcomes once the study and the innovation is completed to both the hospital and to other public health conferences that could find the outcomes beneficial.  

Keywords: Discharge program’, ‘cardiovascular care’, ‘readmissions’, ‘emergency department’, ‘transition of care’. 

 

 

Viability Study of Initiating a Designated Discharge Nurse Education Program in a Public

                                                            Hospital

Introduction

Readmissions into hospitals continue to be one of the greatest challenges that is facing the health care system throughout the world. The probabilities of a cardiovascular paediatric patient getting readmitted within 90 days after they are discharged are a high as one in every five patients and it is worse for paediatric a cardiovascular case which is one in every four children (Weiner et al., 2009). In the contemporary years, there has been an amplified determination to try and shrinkage the hospital readmissions in order to try and lessen the expenses that are associated with readmissions and also as a supposed ration of care value. This has encompassed care direction for high readmission conditions and patients, improved discharge preparation and self-supervision as well as training during the post discharge conversion period (Mackie et al., 2008). Little exploration has nevertheless fixated on the emergency department (ED) calls following an inpatient admission.

The ED visits have significantly augmented in the last decade most specially for the children with cardiovascular conditions. The ED does not only play the significant role for patients that come back after they have been released from the hospital.   It also aids in avoiding the requirement for lengthier inpatient stay for the well scheduled visits. The cause of the return patients can be blamed on the discharge process that is used in hospitals. In the United States, there is an average of about 9,706 patients that are discharged every single day (Mackie et al., 2008). Despite this relentless occurrence of the paediatric hospital discharge, crucial queries about the procedure of discharge still go unrequited. Some of these questions include the type of discharge care offered, the routine in which discharge care design should ensue from the commencement to the conclusion and the roles that the nurses and the parents should play in influencing the discharge strategy (Naylor et al., 2011).  The fact that there are no comprehensive responses to these questions destabilizes the worth of paediatric hospital discharge and it deters the eminence enhancements efforts and it undesirably disturbs the health and comfort of children most especially those with cardiovascular difficulties once they leave the hospital (Whicker, 2015). The purpose of this project is to aid in informing the paediatric providers about the key components of exceptional discharge preparation, how effective a discharge nurse education program would be and the ways that it can effectively be implemented in public hospital settings.

Ethical considerations

Research in general entails the deliberation of ethical values; the research that is steered in the healthcare territory most specifically carries precise ethical ideologies linked to human issues. The Institute of Medicine (IOM) recognises core magnitudes of eminence wellbeing, efficacy, patient-centeredness, appropriateness, parity, and efficacy which connect to foundational central ethical values (AHRQ, 2018). The consent from the parent or the caregiver of the subjects is of paramount importance and is a central constituent of clinical research integrities (Melnyk & Fineout-Overholt, 2018). All healthcare research must be scrutinized for the significance of research to improve the quality of service delivery. Inclusion and exclusion criteria of subjects should be based on the scientific rationale (Heale, & Shorten, 2017). Ethical ideologies affect both the significance of evaluating the effect of evidence on patients and the way in which these valuations are carried out (Melnyk & Fineout-Overholt, 2018). Judkins-Cohn et al., (2014) stress that research must have purposeful meaning – scientific validity and generalizability are essential to all undertakings in order to ensure that resources are efficiently and effectively utilized.

Any expectation of publishing the results of the PICO research must follow guidelines related to generalizability so findings can be repeated in other patient populations. If the project fails to employ clear methodologies and organized design adhering to the evidence-based practice (EBP) process, time spent to undertake the project could be determined as a wasteful use of resources (Melnyk & Fineout-Overholt, 2018). Considering equitable distribution of research resources within the Johns Hopkins All Children’s Hospital organization, is a fundamental ethical principle related to the protection of quality care for other patient populations. Further, determining who receives a designated discharge educator versus discharge education being conducted by the staff nurse (current practice) must be unbiased and randomized to adhere to ethical principles related to the protection and wellbeing of all study participants (Melnyk & Fineout-Overholt, 2018). The wellbeing of all participants must be considered and the project should be aborted or deferred for review if any identification of injustice arises. Nevertheless, research ethics requires that if a patient, parent or caregiver requests the involvement of a designated educator regardless of study group, the request must be fulfilled and thus be reported in the results (Heale & Shorten, 2017). 

The PICOT Question

To achieve the literature search in this project the PICOT question was first identified: In paediatric cardiovascular ICU patients (P) how does discharge education/planning by a designated discharge nurse education program (I) compared to education provided by many nurses over the length of hospital stay (i.e., current practice) (C) affect ED visits and hospital readmission rates (O) within 90 days of discharge (T)?

Research strategy

Research of this inquiry employs multiple research platforms – randomized -controlled trials (RCTs), methodical evaluations, meta-analysis, case studies – from peer reviewed journal articles and gathered from ICU setting current practices. Databases utilized in the initial search include Cochrane Library, PubMed, CINAHL, and Science Direct. The project topic area is an evidence based practice change with the aim of generalizability to other patient populations. Research is fixated on queries for which responses are not recognized. When it is not understood whether one intervention is better than the other, then the best technique is through a randomized controlled trial. To fulfil the objectives of the study, an operational selection process of the current literature was mandatory.

            The consistency and reliability of any research conclusions are resultant based on the aptitude of the selected literature to effectively respond to the research question. Systematic review involves a literature review that visibly addresses the framed research question while using categorical and methodical research methods (Melnyk & Fineout-Overholt, 2019). Here, it was essential to limit the database through the use of filtering publication utilizing “and” and “or” commands.  The procedure trailed a clear set of diverse approaches such as catalogues and key terms that were used all through the examination approach. Some of the key terms that were used in the research included ‘discharge program’, ‘cardiovascular care’, ‘readmissions’, ‘emergency department’, ‘transition of care’.  For this research, the following databases were used CINAHL, MEDLINE®, Joanna Briggs Institute, PsycINFO, Trip, and PubMed. Adding specific MeSH terms to the PubMed search builder was the most helpful for me when seeking to narrow my searches. These databases store valid resources in this field of research.

            The sources were chosen because they are the most reliable academic databases and also because of their capacity to provide widespread peer-reviewed sources to respond to the research question. The literature was chosen on the root of significance to the research topic, dialect, publication date, authors, publication, and number of citations. With deference to the inclusion principles the researcher only sort to integrate current studies based on their aptitude to offer pertinent and reliable data. All the selected research articles had a noteworthy sum of citation for the raised argument which established their correctness and significance. Age group was also fundamental to consider so that the research is narrowed down to avoid the use of own keywords like paediatrics. Non-English sources were also disregarded to elude the issue of language barrier which could lead to misunderstanding. The study used a total of 10 peer reviewed articles.

Critical Appraisal of the Evidence

Rapid critical assessment specifications were utilized to help assess the rationality, consistency and applicability to the practice. For all of the studies that were established from the study counting the methodical review by Naylor et al., 2011, the meta-examination by Weiner et al., 2009 and several other randomized controlled trials have reinforced the use of discharge education programs for the ICU cardiovascular paediatric patients. In the course of the search procedure, the interferences that were appropriate to paediatric practices were recognized in the articles recounting innovative discharge programs approaches and the cooperative care simulations in which the nurse specialists can action as a distribution system to help in the discharge course. The discharge program is an element that can be used to help reduce the cases of readmissions for the paediatric patients and it is something that parents, nurses and the whole health care fraternity at large can help implement by creating room for discharge nurse education program.

The research studies selected for this study have approached the subject of their inquiry with thoroughly researched methodological designs. The studies have used appropriate study samples that include cardiovascular paediatric cases and nursing practices as their main themes with the required approvals for the studies acquired making the studies very reliable. The studies have all used descriptive, correlational and statistical designs which are very appropriate for the studies. With DeWit & O'Neill, 2013 the study has used the MSNS statistical instrument with the response scale ranging from 1-7 from ‘strongly approve’ to ‘strongly disapprove’. The data assimilated from all this studies is within acceptable restrictions of steadiness as well as precision. With Nosbusch et al., 2011 the age range of the contestants in the study is fairly extensive and it signifies both the knowledgeable and the inexperienced nurses which could bring in some errors in the data collected. Most of these studies including ‘DeWit & O'Neill, 2013, Brooten & Naylor, 1995, Mamo et al., 1992, Nosbus et al., 2011 and Weiner et al., 2009’ require further research in order to help determine how effective their findings are in regard to the discharge nurse education program to help with the frequent readmissions for the ICU paediatric cardiovascular patients. As for the other studies, their findings are concrete and in reference to the data that is acquired and the variables used, they clearly show the effects that the distinct discharge nurse education program would have on the paediatric cases to help reduce the ED visits.

 

Figure 1; a table presenting the research evidence

Study	Purpose	Conceptual Framework	Method	Sample Setting	Major Variables Studied	Measurement of major variables	Data analysis	Study findings	Feasibility conclusion
Brooten, D., & Naylor, M. D. (1995)	Changing patient outcome	DV-outcome of the patients IV- Nursing concepts	Evaluation	Paediatric patients	Nursing practice	Outcome	Comparison	Low outcome	Further research needed
DeWit, S. C., & O'Neill, P. A. (2013)	Concepts and skills for nursing	DV- nursing skills IV- Nursing concepts	Evaluation	Paediatric patients	Concepts in nursing	Concepts	Measurement	High impact	Further research still needed
Mackie, A. S., Ionescu-Ittu, R., Pilote, L., Rahme, E., & Marelli, A. J. (2008)	Hospital readmissions	DV- Hospital readmission IV- Anxiety pressure	Description	Children with congenital heart disease	Readiness	Impacts	Comparison	Low impact	The evidence is concrete
Mamon, J., Steinwachs, D. M., Fahey, M., Bone, L. R., Oktay, J., & Klein, L. (1992)	Impact of hospital discharge planning	DV-discharge planning IV- Consent	Evaluation	Paediatric	Hospital discharge	impacts	Comparison	High impact	More research needs to be conducted on the area
Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011)	Importance of transitional care in achieving health reform	DV- Health reform IV importance of care	analysis	Paediatric patients	Transitional care	impacts	Analysis	Low impact	Evidence is consistent
Nosbusch, J. M., Weiss, M. E., & Bobay, K. L. (2011)	Challenges confronting the acute care staff nurse in discharge planning	DV- discharge planning IV -challenges	descriptive	Nurses	Acute care	challenges	Investigate	High outcome	Further research is required
Phillips, C. O., Wright, S. M., Kern, D. E., Singa, R. M., Shepperd, S., & Rubin, H. R. (2004)	Planning with post discharge support for older patients	DV- Post discharge IV- planning	analysis	Patients	Post discharge support	Impact	Investigate	Low influence	Evidence is consistent
Weiner, P. L., Hoffman, M., & Rosen, C. (2009)	Chronic illness or special health care needs	DV-special health care IV- Illnesses	Descriptive	Children	Special needs	Special health care needs	Analysis	High prevalence	More data needs to be analysed
Whicker, M. A. (2015)	Influence on patients’ continuum of care	DV- Continuum care  IV- influence on the patients	Evaluation	Patients	Continuum care	Quality of care	Comparison	High influence	The area needs to be further studied.
Davies, S. (2018)	Transitional care for cardiac surgery  patients	DV- transitional care IV- The effects on the patients	Evaluation	patients	Transitional care	concepts	Comparison	High impact	Study is concrete

 

Evidence Assimilated with Patient Partialities and Clinical Proficiency

The Institute for Healthcare Improvement (IHI) takes a cohesive tactic to refining the health structure by try to augment the per capita rate, involvement of the distinct and general attention of the populace.  Evidence- grounded attention is a crucial element of the IHI as amalgamation of it or deficiency disturbs the scopes involvement of the patient that pursues to advance the gratification, the value, and populace wellbeing (Institute for Healthcare Improvement, 2019).  With reflection of introducing a discharge nurse education program, the constituents of the IHI must to be evaluated.

            Cost contemplation is one of the features in the IHI.  Regrettably, nevertheless, is the fact that cardiovascular problems in children are one of the peak fee syndromes where most children are looked after in the hospitals.  While it is okay to say that the worth existence of human beings should not be equated using a number, decreasing the price of situations that are lifesaving is still a significant objective in the healthcare sector.  One approach through which this can be attained is having a trained nurse oversee the progress of these cardiovascular ICU patients even when they are discharged from the hospital ((Naylor et al., 2011).

            Patient inclination is another problematic topic when allowing for discharge nurse program.  It is essentially quite inherently connected in many phases to the ethical characteristics of the remedy.  Having progressive commands or a living willpower is an ideal technique of guaranteeing that the patient inclinations regarding their health maintenance is being appreciated (Mamon et al., 1992).  Numerous patients may not aspiration for valiant dealings like having private nursing services at their homes just to have their health checked.  If that is their longing, this rations need to be valued and perceived.  In the acute care unit, getting hold of such brochures or having health precaution substitutes that can make decisions on behalf of the patients and honour their requirements is a technique that patients can endure in order have self-sufficiency even when they are too weak to direct their requirements.

            Clinical proficiency is essential to offering actual discharge nurse program to patients.  The clinicians’ coverage to the research discoveries in tallying to their training and prior involvement with patients on the discharge program is vital in being capable of correctly managing, troubleshooting, and determining matters in times of disasters once the patients have been discharged (Phillips et al., 2004).  Those clinicians who will be involved in the discharge education program will need selected preparation courses to prepare themselves for management of this sort of care. Supplementary approvals include that centres necessitate clinicians to complete annual inspections concerning the care program will be essential in a public health facility  situation whose yearly work load will probably be meaningfully lesser than that of a theoretical capacity.

Plan to Implement Project

The leading phase in gathering backing for the exercise change of evaluating the possibility of founding a discharge nurse education program at a public health facility is to first craft an image within the facility structure of the founding of an evidence-grounded drill for this rehabilitation and appealing to both employees and assets.  This must comprise classifying key investors and attainment of their backing as well as managerial backing (Davies, 2018).  Investors are individuals who have the aptitude to distress a plan and civilizations that will be precious by the scheme.  The extent to which they are involved will be swayed by the impact that they have and their extent of concern or contribution.  The Discharge nurse education program is not the effort of a solitary individual but an intricate conduct modality that necessitates the partnership of numerous spheres and crews (DeWit & O'Neill, 2013).

 For operative procedure change to integrate discharge nurse education program at a public health facility, true partnership among interdisciplinary crew associates, including subsidiary staff is important.  For this project, investors will comprise the critical care crew including critical care doctors and nurse specialists who will accomplish the everyday care of the ICU cardiovascular patients on the discharge programs and who will be significant in the crafting of conventions for the course modification.  Cardiovascular doctors who have previously requested discharge nurses for their patients who have difficulty coping once they were discharged are also important participants. Administrative sustenance and hospital management who have the authority to effect change are also important.  The ICU administrator and the medical administrator of the hospital are revolution frontrunners who require being perceptible and reachable for support throughout execution.  The chief financial officer will also require being included in the program as this exercise transformation will be at first very supply involved due to apparatus, tutoring, and generally all the costs that are obligated (Davies, 2018).  The chief decision-making captain of the health care facility, given that this is a public hospital and this implementation change is noteworthy, will also require to give accord and also be conscious of the deliberated transformation.
            To instigate the project, the undertaking of including the patrons, a course transformation frontrunner will first be allocated.  This head will be an associate with extraordinary connection and impact in the course with the enthusiasm and sustenance of a great quota of the staff and benefactors.  For the discharge nurse education program, it will comprise a physician discharge nurse administrator with the accountability for the general action of the discharge errands.  The health executive for the discharge program should be an individual with experience in matters of critical care, cardiovascular expert, or a board-qualified professional with explicit knowledge in cardiovascular matters and should have widespread critical care experience (DeWit & O'Neill, 2013).  A second frontrunner will be the discharge nurse education program director, which will be given the work of supervising and training the nurses, the upkeep of equipment, and assortment of patient statistics.  These frontrunners will then effort on finding other investors from the groups above-mentioned to form a discharge nurse education program board. 

To achieve the participation of other investors, the frontrunners will want to enlighten them on the reasons their contribution is significant and the developments that would be ensuing from it.  irrespective of whether it is through representing evidence-based exploration, description of patient case researches, quoting a custodian occasion that came about because of the harmful result of not posing this discharge program in society (DeWit & O'Neill, 2013). And also citing financial examination that backs the program development initiative, or even motivating the medical employees through specialized awards for contribution in a board, the front-runners of this project will need to look for the most powerful technique of attaining tactical investors contribution (DeWit & O'Neill, 2013).  Relating consultants and specialists from other organizations who have positively applied such an exercise transformation and can aid in mentoring the practice transformation and voice to the investors’ worries is also expected to be an actual approach.  Finally for involvement, participants must be made to identify that there is a major issue with the upkeep of these disapprovingly ill patients once they are discharged from the hospital and that only with their involvement, participation, and connection, can lead to an adequate program implementation that will be useful to their securities, the patients', and the foundation at large.

            Preceding the implementation of the practice revolution and essentially instigating the discharge nurse education program, the board needs to strategize and consolidate.  Preparation for a practice revolution may require the formation of a tactical plan that comprises the board’s general undertaking, vision, and objectives comprising both short-range justifiable aims and long-standing idealistic aims.  By this time, the viability portion of the plan must be methodically accomplished and revised and considered practicable.  One technique to aid assemble the exercise transformation is over the application of a procedure upgrading outline.  The agenda that will be used for the discharge nurse education program is the Model for Improvement (MFI).  This model has been selected for application grounded on its simplicity in use for hastening progress and its authorization by the Institute for Healthcare Improvement (IHI).  The MFI comprises a set of queries that effort the upgrading.  By dividing the outline up into these units, operators can first attention and describe the issue at hand, the planned resolution, and processes that establish the result of this resolution’s execution (The IHI Triple Aim, 2019).  This strategy could comprise a Strengths, Weakness, Opportunities, and Threats (SWOT) scrutiny where valuations of the establishment of this program conversion is analysed.  The SWOT analysis aids in ranking scientific problems, guarantee that the assets are accessible, the range of amenities is correct, the accessible expertise and tools meet the mandated criterions, the employees obtains the satisfactory training and learning, and that procedures to quantify, scrutinize, and assess the intercession and practice modification are set and ready (The IHI Triple Aim, 2019).
            The precisions attained from the first segment are utilized to govern the strategy of operation, dimension, and change approaches grounded on the data measured through the test of modification.  Test of change includes the strategy to implement the discharge nurse education program on incremental ranks, such as initiating it with only very specific patients who have been back to the emergency room several times after discharge and then later expanding it to more patients even those with different diagnosis.  Based on these checks of transformation, strict policy and actions outlining the suggestions, contraindication for discharge nurse education program, scientific control of the patient, upkeep of the program, closure of the program and development of the discharge nurse education program patients can be generated and made available for evaluation.

Obstacles

Some of the main obstacles anticipated in executing this venture will be fiscal expenses. In any project, it is important to have enough finances to help implement an effective plan that is viable (Brooten & Naylor, 1995). While management is presently supportive of the notion of an educational program for designated discharge nurse in paediatric cardiovascular cases, it does not yet understand the structure wide inferences of having such a program and the direction that is required to have a concrete program.  When the practicability study is finalized, then there will be need to have a sequence of conferences scheduled to analyse the outcomes with crucial managerial investors to manage the finances and also the distribution of assets for the program.  Another inhibition to the project execution is creating the organization of crew associates to take charge of the discharge educational program. 

While many team acquaintances are presently keen concerned about the idea, a noteworthy volume of time is required to devote to ground for those team affiliates who really want to go along with this program.   Re-establishing their existing work timetables in the health care facilities and also dealing with other patients at home may be critical in order to assign adequate time and preparation to found an operative group (Brooten & Naylor, 1995).  In conclusion, recognized nurses that work in the ICU have previously articulated their worries about taking care of patients on yet an additional new system of recovery that is new to them. To avoid undesirable approaches or antagonisms to advancing care of patients by the introduction of a new remedy, timely and thorough training of the staff on the innovative performs, actions, and analysis that the discharge educational program will convey to the critical care section is important.

Pre- Execution Activities

Because this is a viability research on a scheme that has never been executed at John Hopkins All Children’s Hospital, this study contains only secondary research, not primary research. The results will be collected and analysed from data that exist in on discharge nurse education programs that have already been established across the U.S, gathered from Medicare billing encryptions, and recently printed linked charges of the discharge program in hospitals.  The outcomes analysed will include; the death rate, rate of hitches, charge per day of analysis, and net revenue or loss.
            The statistics on death and hitches in the objective populace is essential and it shall be gotten from the Joint Commission International (JCI) archive system.  This statistics is gotten by questioning JCI in order to get data on patient results from its US archive system. Facts and statistics from the JCI inventory network is normally submitted by member organizations to the archive.  This data comprises sex, race, nature and brutality of disease, the consequence of the discharge program in relation to the emergency department return patients rates (Joint Commission International, 2019).  The data unruffled from JCI registry is pre de-recognized by JCI and affiliate organizations excluding for birth dates and periods of provision using designs within the catalogue.  The hub ID is utilized only for eminence guarantee reports (Joint Commission International, 2019).  Information is offered only either in summative or deprived of the centre identifier.  Archive statistics is accessible only to dynamic contributing JCI members. John Hopkins Hospital joined JCI in the year 2014 and it received its three years gold approval in 2017 which makes it a viable member to request and gets data from their archive (John Hopkins All Children Hospital, 2019). No IRB endorsement is required from John Hopkins All Children Hospital, as no data is collected from patients at the hospital during the viability valuation project.

Prospective funding strategies

There are only two conceivable funding sources for any critical care venture by nurses looking into the practicality of health care has been explored. in this case being the issue of research is the implementation of distinct discharge nurse education program for cardiovascular paediatric ICU patients.  The main source that would be relevant for this study is through the American Association of Critical-Care Nurses.  The offers a vital foundation of clinically pertinent exploration for generating evidence-based assets that inspirations practice in high perception life-threatening care extents through is impact research grants (American Association of Critical-Care Nurses, 2019).  The requirements for this funding are for the main researcher to have achieved a master’s degree and should also be a member of the AACN. There are three funding honours where each can be accessed on yearly basis, and one can acquire up to $50,000 for honour (American Association of Critical-Care Nurses, 2019). The second opportunity is with Society of Critical Care Medicine (SCCM) which offers a probable funding through its Norma J. Shoemaker Grant.  The funding is set in sustenance of exploration studies of any nursing member of the SCCM, it offers an average of about $15,000 funding for up to two years (Society of Critical Care Medicine, 2019).  The candidates that qualify for this funding must members of the SCCM with a standard character and they also must have attended at least one SCCM senate in the last three years (Society of Critical Care Medicine, 2019). 

Plan to publicise the findings of the project

Distribution of outcomes is important for continuing practice revolution as it helps to overawe information discrepancies, expertise debits as well as uncertainty, endorse knowledge distribution to highlight the requirement for transformation and recognize optimistic results of change.  Distribution ought to be internal to the main staff as well as the managerial investors and also peripheral to the larger community.  As the discoveries of the viability project are exposed, the data should be distributed to other hospital associates who include the managerial investors, general practitioners, and basically all the health care employees, this facts would be ideally be conveyed at health care summits. The data garnered from the viability research could also hypothetically be of concern to numerous other health centres with emergency departments.  So, offering the plan for poster exhibition during professional summits such as at the JCI discussions, or any form of health care summits for instance the yearly Society of Critical Care Medicine Congress.

 

 

 

 

 

 

 

 

 

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