Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital: The READI Randomized Clinical Trial

Abstract

Importance: The downward trend in readmissions has recently slowed. New enhancements to hospital readmission reduction efforts are needed. Structured assessment of patient readiness for discharge has been recommended as an addition to discharge preparation standards of care to assist with tailoring of risk-mitigating actions.

Objective: To determine the effect of unit-based implementation of readiness evaluation and discharge intervention protocols on readmissions and emergency department or observation visits.

Design, setting, and participants: The Readiness Evaluation and Discharge Interventions (READI) cluster randomized clinical trial conducted in medical-surgical units of 33 Magnet hospitals between September 15, 2014, and March 31, 2017, included all adult (aged ≥18 years) patients discharged to home. Baseline and risk-adjusted intent-to-treat analyses used difference-in-differences multilevel logistic regression models with controls for patient characteristics.

Interventions: Of 2 adult medical-surgical nursing units from each hospital, 1 was randomized to the intervention and 1 to usual care conditions. Using the 8-item Readiness for Hospital Discharge Scale, the 33 intervention units implemented a sequence of protocols with increasing numbers of components: READI1, in which nurses assessed patients to inform discharge preparation; READI2, which added patient self-assessment; and READI3, which added an instruction to act on a specified Readiness for Hospital Discharge Scale cutoff score indicative of low readiness.

Main outcomes and measures: Thirty-day return to hospital (readmission or emergency department and observation visits). Intervention units above median baseline readmission rate (>11.3%) were categorized as high-readmission units. Among the 33 intervention units, 17 were low-readmission units and 16 were high-readmission units.

Results: The sample included 144 868 patient discharges (mean [SD] age, 59.6 [17.5] years; 51% female; 74 605 in the intervention group and 70 263 in the control group); 17 667 (12.2%) were readmitted and 12 732 (8.8%) had an emergency department visit or observation stay. None of the READI protocols reduced the primary outcome of return to hospital in intent-to-treat analysis of the full sample. In exploratory subgroup analysis, when patient self-assessments were combined with readiness assessment by nurses (READI2), readmissions were reduced by 1.79 percentage points (95% CI, -3.20 to -0.40 percentage points; P = .009) on high-readmission units. With nurse assessment alone and on low-readmission units, results were mixed.

Conclusions and relevance: Implemented in a broad range of hospitals and patients, the READI interventions were not effective in reducing return to hospital. However, adding a structured discharge readiness assessment that incorporates the patient's own perspective to usual discharge care practices holds promise for mitigating high rates of return to the hospital following discharge.

Trial registration: ClinicalTrials.gov Identifier: NCT01873118.

Figure 1.. Study Sample Flow Diagram

Figure 2.. Analysis of Readiness Evaluation and Discharge Interventions (READI) Effectiveness for Intervention Units With Low (≤11.3%) and High (>11.3%) Readmission Rate at Baseline

Difference-in-differences predictive margins with 95% CIs (error bars) of the absolute percentage point reduction from the READI intervention by protocol, estimated using a multinomial conditional likelihood difference-in-differences logistic model with adjustment for baseline event rates and patient characteristics with clustering at unit and hospital level. The READI1 protocol used the nurse form of the Readiness for Hospital Discharge Scale (RHDS) with instructions to nurses to use their best judgment with the assessment information to guide actions in completing their patients’ preparation for discharge. The READI2 protocol used patient self-assessment using the patient form of the RHDS followed by nurse assessment using the nurse form of the RHDS with instructions to nurses to use their best judgment. The READI3 protocol used patient self-assessment using the patient form of the RHDS followed by nurse assessment using the nurse form of the RHDS with instruction to nurses to act and document nurse actions if the patient received a low readiness score (<7) on the nurse or patient form. ED indicates emergency department.