พว. ส ท ศา ป ต ญาณ พยาบาล APN ฝ ายการพยาบาลโรงพยาบาลศ ร ราช

Unplanned readmission to the hospital within 30 days of discharge is considered a sentinel event for poor quality of hospital care Frankl S.E., Breeling J.L., Goldman L. Preventability of emergent hospital readmission. Am J Med. 1991;667 674 As many as 79% of readmissions are considered preventable and a direct result of uncoordinated care. Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599-605. Hospital readmissions are costly to patients and healthcare facilities. Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015:18-20.

IDEAL Discharge planning method By The Agency for Healthcare Research and Quality (AHRQ) Include Discuss Educate Assess Listen https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engag ingfamilies/strategy4/strat4_implement_hndbook_508_v2.pdf

Include: the patient & family as full partners in the discharge planning process; bedside rounds shift reports review medications daily and at each dose administration Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Include: Identify which family members or friends will provide care at home and include them in conversations Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Include: Include the patient and family in team meetings about discharge at least 1 meeting at least 1-2 days before discharge Remember that discharge is not a one time event but is a process that takes place throughout the hospital stay Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Discuss Review medications (reconciled medication list); how much to take how to take it potential side effects Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Discuss To prevent problems at home, describe what life at home Environment Support needed Dietary changes Activities to do/ avoid Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Discuss Offer to make follow up appointments for the patient Make sure that the patient and family know what follow up is needed Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Discuss Explain test results to the patient & family If test results are not available at discharge, let the patient and family know when they should hear about results and identify who they should call if they have not heard the results by that date Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Discuss Highlight warning signs & problems give contact information of someone to call if there is a problem Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Educate : Encourage the patient and family to take part in care practices to support their competence and confidence in care giving at home Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Educate : the patient and family in plain language about the patient s condition the discharge process at every opportunity throughout the hospital stay Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Educate : During the hospital stay, you can: Elicit patient and family goals at admission and note progress toward those goals each day Involve the patient and family in nurse bedside shift report or bedside rounds Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient s care to the patient and family and use teach back Provide information to the patient in small chunks and repeat key pieces of information throughout the hospital stay the patient and family to repeat what you said back to you in their own words to be sure that you explained things well Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Listen to and honor the patient and family about The patient and family s goals, preferences, observations, and concerns Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Listen Invite the patient and family to use the white board in the room to write questions or concerns Ask open-ended questions to elicit questions and concerns Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Listen Schedule at least one meeting specific to discharge planning with the patient and family caregivers Nelson J. M. & Rosenthal L. How nurses can help reduce hospital readmissions: Learn how to help mitigate readmission risk starting from the time of admission. The Essence of Nursing. 2015.18-20. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/s trategy4/strat4_implement_hndbook_508_v2.pdf

Transition record: Principle diagnosis and problem list Patients cognitive status Test results/ pending results Medication list (Reconciliation) including over the counter medication/ herbals/ allergies, and drug interactions Patient s medical home or transferring coordinating healthcare provider/ facility and contact information Emergency plan, contact person, and contact number Prognosis and goal of care Treatment and diagnosis plan Planed interventions; wound care Advance directives, power of attorney and informed consent Caregiver status Polster D. Preventing readmissions with discharge education: Arm your patients with tools for success. Nursing Management. 2015: 30-37.

Siriraj Continuing Care

งานการพยาบาลปฐมภ ม ส ทธ บ ตรทองศ ร ราช หน วยการพยาบาลต อเน อง ส ทธ อ นๆ

งานการพยาบาลปฐมภ ม

โทร 9-8326 งานการพยาบาลปฐมภ ม

หน วยการพยาบาลต อเน อง

โทร 9-9293, 9-9645 หน วยการพยาบาลต อเน อง