Impact of COVID-19 Visitation Policies and Hospital Capacity on Discharge Readiness in Medicine Patients

doi:10.21203/rs.3.rs-3335049/v1

Download PDF

Research Article

Impact of COVID-19 Visitation Policies and Hospital Capacity on Discharge Readiness in Medicine Patients

https://doi.org/10.21203/rs.3.rs-3335049/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

COVID-19 impacted the experience of being hospitalized with the widespread adoption of strict visitation policies to ensure healthcare worker safety. One result was decreased time of caregivers at the bedside of hospitalized patients.

Objective

To understand the impact of pandemic-related system effects on patient-reported discharge preparation.

Design

This mixed methods study included interviews with a sample of discharged patients during April 2020, and quantitative hospital data from April 2020 to February 2021.

Participants

616 patients completed a measure of discharge readiness on their day of discharge and 38 patients completed interviews about their discharge experiences.

Main Measures

Readiness for discharge (RHDS), visitation policies, ward structure changes, COVID-19-unit census, time into the COVID-19 pandemic, patient characteristics (age, sex, race/ethnicity), admission type (planned/unplanned, for COVID-19), and discharge destination (home, home health, skilled nursing).

Key Results

Adult patients aged 30–45 (vs young and older adult patients) and those being discharged to places other than home (e.g., skilled nursing facility) or to out-of-state residences report lower readiness (p < .05) on RHDS. Patient interviews revealed some gaps in discharge communication but, overall, patients expressed high discharge readiness and few concerns about how COVID-19 system changes impacted their discharge preparation.

Conclusions

While there is some evidence that visitation policies and unit census may impact patient perceptions of discharge preparation, personal characteristics contributed more significantly to discharge readiness than system changes during COVID-19. Participant interviews demonstrated agreement, as most participants were discharged home and identified strong personal feelings of readiness for discharge.

Clinical Trials Registration:

The parent study from which the secondary data described in this paper were collected is registered in ClinicalTrials.gov ID NCT04248738 (January 27, 2020), https://clinicaltrials.gov/ct2/show/NCT04248738

Care Transitions

Discharge Planning

Health Care Quality

COVID-19

Beginning in March 2020, hospitals experienced immediate decreases in hospitalizations that then rapidly rebounded to pre-pandemic levels by summer 2020.¹ While ED visits then decreased, hospital admissions increased due to sicker patients requiring admission.² As a result of these rapid shifts in hospitalizations, additional pressure was put on staffing and discharge throughput.^3,4 By April 2020, nearly all academic hospitals had developed new respiratory isolation units and described disruption in typical rounding structures that included health professionals rounding separately: 90% of sites decreased in-room encounters across all provider types.⁵ As a result, team disruptions may have led to decreased communication and collaboration around discharge planning.⁶

Meanwhile, for patients and families, the experience of being hospitalized was directly impacted during COVID-19 by visitation policies.⁷ Restrictive policies ensured healthcare worker (HCW) safety but presented a trade-off of decreased time of caregivers – unpaid family or friends – at the bedside of hospitalized patients. Importantly, high-quality discharge planning includes patients and their caregivers and is critical to understanding barriers to safe discharge and the effectiveness of discharge teaching. ^8–11 Actively engaging caregivers in hospital discharge processes is associated with as much as a 25% decrease in hospital readmissions.^12,13

While it is likely that COVID-19 pandemic conditions adversely affected the quality of discharge preparation and created additional barriers to patients’ ability to recover in the community after discharge, there is little information about whether or how the system changes related to the pandemic impacted the quality of discharge preparation, and which patients may have been most impacted. In this study, we sought to understand the impact of COVID-19 through qualitative interviews with patients who were discharged into a locked-down community, and quantitative analyses exploring how COVID-19 changes within the hospital, personal characteristics, and discharge destination impacted patient-reported discharge readiness.

This convergent mixed methods study¹⁴ was part of a larger parent study aiming to improve the quality of discharge planning from a quaternary care academic health sciences center University Hospital in the Intermountain West. Interviews were conducted with a sample of discharged patients during April 2020, and quantitative analyses were conducted on hospital data survey and administrative data collected between April 22, 2020 to February 9, 2021. The study was approved by the University of Utah Institutional Review Board.

Measures

For the qualitative portion, we developed an interview guide to understand participants’ ability to engage in self-management post-discharge, and to explore whether and how the discharge planning process identified potential needs post-discharge and contributed to successful transitions home after hospitalization. (See Supplementary Material.)

For the quantitative portion, the primary outcome measure was the eight-item Readiness for Hospital Discharge Scale (RHDS)^15–19 completed by the patient, assessing four dimensions of readiness that independently and mutually serve as outcomes of discharge preparation: perceptions of physical readiness to care for self (through recognition of availability of supportive persons and resources), knowledge (through education of a support person who can reinforce the information), ability to cope at home, and the level of expected support (having someone to help at home). The RHDS is correlated with quality of discharge teaching; difficulties coping post-discharge; care coordination and utilization of post-discharge services; lower perception of readiness at discharge is associated with increased use of both informal and formal support post-discharge; and hospital readmissions.^18–23 The RHDS uses a 0–10 point rating scale for each item; higher scores indicate greater readiness. A total mean score of less than 7 indicates low readiness and greater risk of readmission.¹⁶

Setting and Sample

Interview participants were identified from those discharged from medical and surgical hospital units in March 2020, who were at least 18 years of age, spoke English (English need not be the first language), were able to communicate verbally, previously completed the RHDS, and indicated a willingness to be interviewed. Interviews occurred until data saturation was reached.

The quantitative sample were patients discharged by general internal medicine (GIM) teams during the first months of the COVID-19 pandemic (April 22, 2020 to February 9, 2021). Patients were at least 18 years of age, spoke English (English need not be the first language), and were able to communicate verbally. Because of the implications for unique discharge processes, patients admitted due to a primary or secondary psychiatric diagnosis; enrolled in palliative/hospice care; residing in a skilled nursing facility (SNF) upon admission; overseen by transplant or bariatric surgical services; seen for unfunded end stage renal disease; and/or prisoners were excluded from this study.

Procedures. After discharge orders were placed into the electronic health record, clinical research coordinators administered the RHDS to patients in person (prior to March 14th ) or on their hospital room phone to comply with COVID-19 safety precautions after March 14th. All qualifying patients on participating units were called, but many were not in their rooms or had already been discharged by the time the call was placed. Informed consent was obtained verbally from all individual participants who completed the RHDS survey.

Patients who completed the RHDS in March 2020 and indicated they were willing to participate in an additional follow-up interview, were contacted via telephone in April 2020. After informed consent to participant in interviews, semi-structured interviews took approximately 30 minutes. Interview participants received a $10 gift card after completion of the interview. Interviews were audio-recorded and professionally transcribed.

Finally, unit occupancy data and dates related to patient visitation policy changes were retrospectively collected from hospital administrative records for all dates between April 22, 2020 and February 9, 2021.

Quantitative Analysis. Numeric variables were summarized with mean and standard deviation (SD); categorical variables are summarized with number and percent. Univariable linear regression models of the RHDS and its 4 subdomains were done for all variables. Multivariable linear regressions were done with analyses exploring hypothesized interactions between discharge destination, admission for COVID-19, and visitor policy. All variables were included in the multivariable models except for variables that we decided to exclude a priori due to possible collinearity with other variables in the models (unit COVID proportion occupied, unit proportion of COVID patients, and admission type).

Some levels of race and ethnicity were combined for regression analysis due to low counts. Long-term acute care (LTAC) was collapsed into the “other discharge destination” category in regression models, which also included acute rehabilitation facility, homeless shelter, COVID-19 hotel, and “left against medical advice”. Unit Census Percentage Occupied was based on total occupancy divided by capacity, while Unit COVID-19 Percentage Occupied was based on the number of COVID-19 patients on the unit divided by capacity. Thus, a 40-bed unit with 20 patients, 4 of whom are COVID-19 patients, would be at 50% Census Percentage Occupied and 10% COVID-19 Percentage Occupied. For these variables, “Proportion” instead of “Percentage” indicates that the decimal value is used instead of the percentage value (e.g. 0.5 rather than 50). Day of Pandemic was based off how many days had passed since the hospital enacted pandemic measures on March 14, 2020. Data collection for this study was briefly halted at that time and restarted on April 22, 2020, so the “Day of Pandemic” variable for this dataset begins on day 39. For models, this variable was converted to “Month of Pandemic” to aid in interpretation of the coefficients. Estimates, 95% confidence intervals (CI), and p-values are reported; statistical significance is defined as p-values less than 0.05. All analyses were conducted using R v4.0.3.

Qualitative Analysis. Transcripts were reviewed for accuracy before coding. Authors A.B., S.R., K.F., and K.S. engaged in coding of the transcripts. Deductive codes were initially created based upon the interview guides.²⁴ Additional inductive codes emerged during coding, were discussed with the team, and then added to the codebook. After coding was completed, we used a thematic analysis process of reviewing codes to discuss and identify key themes.²⁵ Disagreements were documented and discussed during weekly meetings until consensus was reached. Trustworthiness criteria²⁴ were addressed to support rigor throughout data collection and analysis. Credibility was addressed by peer review and weekly team meetings. Additionally, team members reviewed each other’s coding and engaged in reflexivity by discussing biases and assumptions, to ensure accuracy across coding. An audit trail was maintained throughout data collection and analysis.

The quantitative sample included 638 unique GIM patients who completed the RHDS on the day of discharge. Twenty-two readmission events were excluded, bringing the total sample analyzed to 616 first-visit observations. See Table 1 for full demographic information about this sample and the additional 38 patients who completed interviews.

Table 1

Summary Statistics
System Characteristic	Type/Level	Summary
Unit Census Percentage Occupied	[mean (SD)]	68.5 (15.2)
	[range]	(26.3, 97.2)
Unit COVID-19 Percentage Occupied	[mean (SD)]	11.6 (18.1)
	[range]	(0, 72.5)
Unit Ratio of COVID-19 to Non-COVID-19 Patients	[mean (SD)]	26.7 (37.3)
	[range]	(0, 100.0)
Day of Pandemic	[mean (SD)]	210.2 (84.2)
	[range]	(39.0, 332.0)
Total Patient Sample N = 616	Type/Level	Summary
Patient Age	18 to 30	81 (13%)
	31 to 45	180 (29%)
	46 to 60	194 (31%)
	61 to 75	148 (24%)
	76 to 90	13 (2%)
Patient Sex	Female	316 (51%)
	Male	300 (49%)
Patient Race	Non-White	94 (15%)
	Black or African American	17 (2%)
	Asian	13 (2%)
	Native Hawaiian or Other Pacific Islander	19 (3%)
	American Indian	45 (7%)
	Two or More Races	15 (2%)
	White	489 (79%)
	Unknown	35 (6%)
Patient Ethnicity	Non-Hispanic	505 (82%)
	Hispanic	77 (12%)
	Unknown	34 (6%)
COVID-19 Admission	Non-COVID-19 Admission	433 (70%)
	COVID-19 Admission	182 (30%)
Visitor Policy	1 Visitor	379 (62%)
	No Visitors	237 (38%)
Discharge Destination	Home	418 (68%)
	Home Health	124 (20%)
	LTAC	3 (< 1%)
	Other	13 (2%)
	SNF	58 (9%)
Admission Type	Elective (Planned)	28 (5%)
	Urgent/Emergent (Unplanned)	588 (95%)
Patient Readiness for Hospital Discharge - Total	[mean (SD)]	8.4 (1.5)
	[range]	(1.6, 10.0)
Personal Status (RHDS Subdomain)	[mean (SD)]	8.0 (1.8)
	[range]	(0, 10.0)
Knowledge (RHDS Subdomain)	[mean (SD)]	8.2 (2.4)
	[range]	(0, 10.0)
Perceived Coping Ability (RHDS Subdomain)	[mean (SD)]	8.7 (1.6)
	[range]	(0, 10.0)
Expected Support (RHDS Subdomain)	[mean (SD)]	8.7 (2.5)
	[range]	(0, 10.0)
Patient Interview Sample N = 38	Type/Level	Summary
Patient Age	18 to 30	1 (2.6%)
	31 to 45	7 (18.4%)
	46 to 60	10 (26.3%)
	61 to 75	16 (68.4%)
	76 to 90	1 (2.6%)
Patient Sex	Female	23 (60.5%)
	Male	13 (34.2%)
	Unknown	2 (5.2%)
Patient Race	Asian	1 (2.6%)
	American Indian	1 (2.6%)
	White	34 (89.5%)
	Unknown	2 (5.2%)
Patient Ethnicity	Non-Hispanic	36 (94.7%)
	Unknown	2 (5.2%)
Discharge Destination	Home	33 (86.8%)
	Home Health	4 (10.5%)
	SNF	1 (2.6%)
Note. SD = Standard Deviation. LTAC = Long Term Acute Care. SNF = Skilled Nursing Facility. RHDS = Readiness for Hospital Discharge. Missing values: Unit Census Percentage Occupied = 50, Unit COVID-19 Percentage Occupied = 50, COVID-19 = 1

Quantitative Results. RHDS total and subscale scores were most affected by patients’ discharge destination; among non-COVID admissions, those discharged to home health (-0.48 (-0.95, -0.02), p = 0.041) or SNF (-1.39 (-2.04, -0.74), p < 0.001) versus the patient’s own home reported lower overall readiness scores (Table 2). However, on subscale scores (see Supplemental Tables), among non-COVID admissions, those discharged to SNF had lower personal status scores (-1.79 (-2.58, -1.00), p < 0.001) and lower knowledge scores (-1.80 (-2.88, -0.71), p < 0.001), but higher perceived coping ability (-1.62 (-2.34, -0.91), p < 0.001) when compared to those discharged to their own homes.

Table 2

Contributors to Patient Readiness for Hospital Discharge Scale (RHDS) Total Score Variance
Variable	Univariable Estimate (95% CI)	p-value	Multivariable Estimate (95% CI)	p-value
Unit COVID Proportion Occupied	0.36 (-0.33, 1.06)	0.31
Unit Proportion of COVID Patients (of Total Unit)	0.17 (-0.15, 0.48)	0.31
Admission Type
Elective (Planned)	- Reference -
Urgent/Emergent (Unplanned)	-0.46 (-1.03, 0.11)	0.11
Unit Census Proportion Occupied	0.64 (-0.19, 1.47)	0.13	0.95 (-0.07, 1.96)	0.067
Month of Pandemic	0.03 (-0.01, 0.08)	0.13	0.02 (-0.07, 0.10)	0.71
Age
18 to 30	- Reference -		- Reference -
31 to 45	-0.40 (-0.79, -0.00)	0.048	-0.46 (-0.87, -0.06)	0.025
46 to 60	-0.34 (-0.73, 0.05)	0.085	-0.22 (-0.63, 0.19)	0.29
61 to 75	-0.34 (-0.74, 0.07)	0.10	-0.10 (-0.53, 0.33)	0.65
76 to 90	-0.02 (-0.90, 0.86)	0.97	0.06 (-0.82, 0.93)	0.90
Sex
Female	- Reference -		- Reference -
Male	-0.17 (-0.40, 0.07)	0.17	-0.10 (-0.35, 0.14)	0.41
Race/Ethnicity
White Non-Hispanic	- Reference -		- Reference -
Hispanic	0.13 (-0.23, 0.50)	0.47	0.01 (-0.38, 0.40)	0.95
Non-White/Two or More Races	-0.14 (-0.44, 0.16)	0.36	-0.13 (-0.46, 0.20)	0.44
COVID
Non-COVID Admission	- Reference -		- Reference -
COVID Admission	0.20 (-0.06, 0.46)	0.13	0.12 (-0.27, 0.52)	0.53
Visitor Policy
1 Visitor	- Reference -		- Reference -
No Visitors	-0.12 (-0.36, 0.12)	0.33	0.14 (-0.39, 0.67)	0.61
Discharge Destination
Home	- Reference -		- Reference -
Home Health	-0.12 (-0.41, 0.17)	0.42	-0.48 (-0.95, -0.02)	0.041
Other	-1.02 (-1.74, -0.30)	0.006	-0.82 (-1.70, 0.06)	0.067
SNF	-1.29 (-1.68, -0.89)	< 0.001	-1.39 (-2.04, -0.74)	< 0.001
COVID:Discharge Destination
Non-COVID Admission:Home			- Reference -
COVID Admission:Home Health			0.75 (-0.02, 1.52)	0.058
COVID Admission:Other			-2.29 (-4.20, -0.38)	0.019
COVID Admission:SNF			0.94 (-0.20, 2.07)	0.11
Visitor Policy:Discharge Destination
1 Visitor:Home			- Reference -
No Visitors:Home Health			0.25 (-0.42, 0.93)	0.46
No Visitors:Other			1.26 (-0.64, 3.16)	0.19
No Visitors:SNF			-0.31 (-1.17, 0.55)	0.48
Note. SNF = Skilled Nursing Facility. Missing Values: Unit Census Percentage Occupied = 50, COVID = 1; One or more predictors missing: 51 observations

From the interaction between COVID-19 diagnosis and discharge destination we find that relative to non-COVID-19 admissions, COVID-19 patients discharged to a SNF rated their personal status (2.24 (0.87, 3.62), p < 0.001, Supplemental Tables) and coping ability (1.38 (0.14, 2.63), p = 0.030, Supplemental Tables) higher at discharge compared to those discharged to their own home. In contrast, relative to non-COVID-19 admissions those with a COVID-19 diagnosis and discharged to “other destination” reported significantly lower ratings for expected support (-4.81 (-7.98, -1.63), p = 0.003, Supplemental Tables) compared to those discharged to their own home. From the interaction between discharge destination and hospital visitor policy, personal status varied by visitor policy where, relative to when one visitor was allowed, during a no visitation policy, those discharged to “other destination” reported higher personal status (2.55 (0.25, 4.84), p = 0.030, Supplemental Tables) when compared to those discharged to their own home.

Age additionally influenced readiness scores, where adults 31–45 reported the lowest total readiness levels (-0.46 (-0.87, -0.06), p = 0.025, Table 2) compared to the young adults 18–30. Perceived coping ability after discharge varied by age where, again, those age 31–45 reported lower levels than the youngest adults (18–30) (-0.46 (-0.91, -0.02), p = 0.042, Supplemental Tables). No additional differences were found between age categories.

Finally, the only evidence of a system-level factor contributing to variability in discharge readiness ratings was for the expected support subscale, where increased percent occupancy was associated with increased expected support scale scores (1.75 (0.07, 3.44), p = 0.042, Supplemental Tables).

Qualitative Results. Across interviews, participants identified three key themes related to their experiences of hospital-to-home transitions during the pandemic: 1) perceptions of discharge process; 2) influence of personal resources at home; 3) post-discharge impact of COVID-19. (See Table 3 for themes and exemplar quotes)

Table 3

Themes and Exemplar Quotes
Theme 1: Perceptions of Discharge Process During COVID	• “They just gave me the discharge sheet saying I have phone numbers to call and what to look for in case there's complications from surgery, that kind of thing.” (005) • “They didn’t really tell me what to expect, really. And you know, it’s still been going on, and I still don’t really know what to expect.” (015) • “They didn’t tell me what three months from now is gonna look like.” (038)
Theme 2: Influence of Personal Characteristics	• “It's hard to get a hold of my personal doctor out there and then just they stopped taking new appointments. Anything that I need, I'm in a different state. I first have to go through the military with everything and it's seems hard to get ahold of anyone in Utah...But I think my main issue has been the lack of follow-up from Utah and then not having any clear discharge instructions.” (010) • “Unfortunately…my physical therapy I’ve only been able to get two sessions in here in my home. I live in, uh, four hours away from Salt Lake in Idaho and, um, our little community which is Blaine County has had the highest per capita COVID-19 cases in the nation, um, including New York City, um, just by per capita basis.” (014)
Theme 3: Post-discharge Impact of COVID	• “Because you're not able to do it in person [therapy appointment] and they're being sent videos and just the accountability…The accountability. If you're feeling not into it today, you're like, ‘Oh, three sets of 10. I'm going to do two sets of five. Who's going to know?’ You don't have somebody there pushing you and being like, ‘Nope’." (006) • “And I was also supposed to follow up with my urologist when I got back home to make sure I didn't need stitches removed …and my local urologists and urogynecologists both are not even seeing patients in person. They only do on the phone interview and they couldn't help me if my stitches didn't dissolve. So I was sweating and having like a really bad anxiety for the ... they didn't dissolve until six and a half weeks and it was close because I was told do not go, absolutely, do not go past eight weeks, that they should have dissolved in six weeks or less. So that was really stressful.” (009) • “On the positive side, my work hasn’t wanted me to come back. So, my leave has been extended. And that’s made it easier for me to follow through with therapy at home because I have nine more hours a day to be at home.” (022)

Theme 1: Discharge Process During COVID-19

During interviews, participants mostly shared positive experiences of receiving discharge education and information packets. However, several participants identified negative aspects of the discharge process such as instructions delivered while they were not completely aware or were on pain medication. Due to COVID-19 restrictions, one participant shared not receiving verbal instructions, only the printed packet of information. Multiple participants shared feeling ill-prepared to know what to expect after leaving the hospital, particularly after a few months had passed. Overall, while most participants identified receiving helpful discharge education, several shared examples of lacking verbal explanations and experienced limited time spent on discharge instructions.

Theme 2: Influence of Personal Resources at Home

The social resources of interview participants influenced how participants described the discharge process. Most participants identified having support networks at home and shared positive feedback of the discharge process and ability to follow discharge instructions. A few participants shared initial difficulty in performing activities of daily living (such as toileting, showering, etc.) and decreased mobility which became easier after time. Moreover, when participants were asked if they had access to recommended community resources, most denied accessing supportive services or failed to identify a need for community resources since they had support at home.

The experiences above were in contrast to participants with fewer resources or from out-of-state, who shared increased difficulty post-discharge. For example, one participant received preparation for the long car ride but did not receive instructions regarding home care. Another shared that where they are living was experiencing higher rates of COVID-19 that limited ability to follow through with physical therapy appointments.

Theme 3: Post-discharge Impact of COVID-19

The impact of COVID-19 was most clearly seen post-discharge. Several participants shared that COVID-19 restriction resulted in more in-home aid post-discharge or had positive effects on their work situation as they could recover and work from home. In contrast, others discharged to a home in a different state shared struggles accessing resources such as finding available outpatient follow-up and therapy appointments.

In this study, we explored the impact of COVID-19 system changes on patient-reported discharge readiness and transitions home during the pandemic. Our quantitative findings revealed that discharge destination most significantly impacts discharge readiness, rather than system changes during the pandemic, but that impact varies across different readiness constructs. Adult patients (vs young and older adult patients) and those being discharged to places other than home or to out-of-state residences report lower readiness. For those discharged to a community setting other than to home or SNF, variability in the Personal Status discharge readiness subscale was additionally affected by the hospital visitor policy. In support of this finding, our interviews with participants who were primarily discharged to home revealed high personal readiness for discharge and coping. However, this group still noted gaps in discharge communication, homegoing preparation, and experienced barriers to needed follow-up care.

Contrary to what was expected, we found little evidence that the system changes occurring during Covid-19 impacted the overall readiness of patients discharged to home settings, even for those with an unplanned admission. While prior work suggested that higher unit census and larger size of units are associated with lower patient discharge readiness,²¹ the impact of unit on discharge readiness may be driven by additional intrinsic factors such as nursing staff level of education or experience that were not captured in our study. Conversely, it is possible that COVID-19 system changes had limited impact on those who were able to return home and had stable social network and resources, findings that align with other qualitative research conducted with patients from this parent study.²⁶ Further work to associate this with risk of readmission in the setting of COVID-19 and other system disruptions would help determine whether interventions can be tailored to prevent revisits/readmissions by avoiding inappropriate discharge location.²⁷

Across all scales, patients age 31–45 reported feeling less ready for hospital discharge. This suggests there are nuances to patient perception of readiness based on age, and aligns with prior work that found that those younger than 55 years were less ready for discharge on all subscales compared to those aged 55 to 64.²⁸ It has been posited that age-based differences reflect the way that younger patients (< 50) are treated during the discharge process, where assumptions are made regarding the ability to cope at home resulting in less discharge teaching.⁸ Our findings may also reflect the stress that this age range may be expecting in terms of balancing multiple competing priorities, such as work, family, and caregiving responsibilities upon returning home after hospitalization, particularly during the COVID-19 pandemic.

While the majority of prior data on patient readiness for discharge has been limited to patients returning home, one study reported that out of a population of readmitted patients, 28% felt unready to discharge on index hospitalization; this did not vary based on discharge destination.²⁹ Our data contradict these findings, suggesting that the discharge destination has an impact on the patient's readiness to be discharged and, thus, identifying a potential area for improving the quality of discharge support. Decisions to go to an institutional setting such as SNF or LTAC are driven by clinical and functional status, but can reflect a lack of support at home.³⁰ In the realities of clinical practice, discharge teaching regarding self-care is limited for patients discharged to home^21,29 and may be much more limited for patients being discharged to institutional settings, with the assumption they will be receiving ongoing assistance and teaching as needed. However, the fact that non-COVID-19 patients discharged to SNF or LTAC report lower readiness across all readiness subscales likely shows a gap in support in discharge preparation. Similarly, interview participants who were discharged home, but lived in a different state than where they received hospital care, reported experiencing more post-discharge difficulties, which were compounded by COVID-19. Additional preparation may be needed for these patients, particularly when contact with their social networks is disrupted.

This study is limited in several ways. First, the important demographic variable of race/ethnicity was collapsed due to limited numbers represented across categories, and we did not have access to other variables that may better indicate homegoing support such as marital status. Further, while we believe that the system variables created capture contextual system disruptions during each discharge event, we were unable to include other potential variables indicating system disruptions and stressors during the pandemic. For example, given that discharge preparation is a core nursing function, and unit-based nurse staffing has been shown to impact RHDS, future studies should consider more comprehensively exploring whether and how nurse staffing strains during COVID-19 has impacted patient readiness. Additionally, interviews were conducted early in the pandemic with patients who were mainly discharged to home, limiting our ability to qualitatively explore the effect of discharge destination. Finally, we are unable to explain an outlying finding wherein increasing COVID-19 unit census contributed to improved expected support, suggesting the need to perhaps explore this variable and relationship in greater detail.

We found little evidence that hospital census and visitor policies during COVID-19 impacted patient-reported discharge readiness for the larger population of patients discharged from medicine units. Rather, our analyses uncovered patient populations likely in need of additional support during hospital discharge when contact restrictions or staffing limit in-person anticipatory planning: adult (vs younger adult and older adult patients) being discharged to institutional settings. As health systems and clinicians continue to learn from the experiences of COVID-19, efforts aimed at improving hospital discharge, care transitions, and post-discharge outcomes may wish to give focused attention on these populations reporting lower discharge preparation.

Relevant reporting checklist: Per EQUATOR Reporting Guideline Decision Tree, we used the COREQ checklist for reporting the Qualitative aspect of this mixed methods study.

Data availability: The deidentified data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Ethics Approval: This study was approved by the University of Utah Institutional Review Board (IRB# 00126445).

Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States. Health Aff (Millwood). Nov 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
Jeffery MM, D'Onofrio G, Paek H, et al. Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US. JAMA Intern Med. Oct 1 2020;180(10):1328-1333. doi:10.1001/jamainternmed.2020.3288
Khanna S, Boyle J, Good N, Lind J. Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emerg Med Australas. Oct 2012;24(5):510-7. doi:10.1111/j.1742-6723.2012.01587.x
Verelst F, Kuylen E, Beutels P. Indications for healthcare surge capacity in European countries facing an exponential increase in coronavirus disease (COVID-19) cases, March 2020. Euro Surveill. Apr 2020;25(13)doi:10.2807/1560-7917.Es.2020.25.13.2000323
Auerbach A, O'Leary KJ, Greysen SR, et al. Hospital Ward Adaptation During the COVID-19 Pandemic: A National Survey of Academic Medical Centers. J Hosp Med. Aug 2020;15(8):483-488. doi:10.12788/jhm.3476
Carson MB, Scholtens DM, Frailey CN, et al. Characterizing Teamwork in Cardiovascular Care Outcomes: A Network Analytics Approach. Circ Cardiovasc Qual Outcomes. Nov 2016;9(6):670-678. doi:10.1161/CIRCOUTCOMES.116.003041
Weiner HS, Firn JI, Hogikyan ND, et al. Hospital Visitation Policies During the SARS-CoV-2 Pandemic. Am J Infect Control. Apr 2021;49(4):516-520. doi:10.1016/j.ajic.2020.09.007
Weiss ME, Piacentine LB, Lokken L, et al. Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec. Jan-Feb 2007;21(1):31-42. doi:10.1097/00002800-200701000-00008
Robinson MA. Ready, set, go....or not! Alta RN. Sep 2009;65(7):46.
Tell EJ NP, Cohen MA. What Family Caregivers Need: Findings from Listening Sessions. 2021.
Reinhard SC GB, Petlick NH, et al. Supporting Family Caregivers in Providing Care. In: RG H, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality 2008.
Deek H, Chang S, Newton PJ, et al. An evaluation of involving family caregivers in the self-care of heart failure patients on hospital readmission: Randomised controlled trial (the FAMILY study). Int J Nurs Stud. Oct 2017;75:101-111. doi:10.1016/j.ijnurstu.2017.07.015
In: Schulz R, Eden J, eds. Families Caring for an Aging America. 2016.
Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Third Edition. ed. SAGE; 2018:xxvii, 492 pages.
Opper K, Beiler J, Yakusheva O, Weiss M. Effects of Implementing a Health Team Communication Redesign on Hospital Readmissions Within 30 Days. Worldviews Evid Based Nurs. Apr 2019;16(2):121-130. doi:10.1111/wvn.12350
Weiss ME, Costa LL, Yakusheva O, Bobay KL. Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital. Health Serv Res. Feb 2014;49(1):304-17. doi:10.1111/1475-6773.12092
Weiss ME, Piacentine LB. Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. Winter 2006;14(3):163-80. doi:10.1891/jnm-v14i3a002
Weiss ME, Sawin KJ, Gralton K, et al. Discharge Teaching, Readiness for Discharge, and Post-discharge Outcomes in Parents of Hospitalized Children. J Pediatr Nurs. May-Jun 2017;34:58-64. doi:10.1016/j.pedn.2016.12.021
Weiss ME, Yakusheva O, Bobay KL, et al. Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital: The READI Randomized Clinical Trial. JAMA Netw Open. Jan 4 2019;2(1):e187387. doi:10.1001/jamanetworkopen.2018.7387
Weiss M, Yakusheva O, Bobay K. Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization. Med Care. May 2010;48(5):482-6. doi:10.1097/MLR.0b013e3181d5feae
Mabire C, Bachnick S, Ausserhofer D, Simon M, Match RNSG. Patient readiness for hospital discharge and its relationship to discharge preparation and structural factors: A cross-sectional study. Int J Nurs Stud. Feb 2019;90:13-20. doi:10.1016/j.ijnurstu.2018.09.016
Mabire C, Coffey A, Weiss M. Readiness for Hospital Discharge Scale for older people: psychometric testing and short form development with a three country sample. J Adv Nurs. Nov 2015;71(11):2686-96. doi:10.1111/jan.12731
Schmocker RK, Holden SE, Vang X, Leverson GE, Cherney Stafford LM, Winslow ER. Association of Patient-Reported Readiness for Discharge and Hospital Consumer Assessment of Health Care Providers and Systems Patient Satisfaction Scores: A Retrospective Analysis. J Am Coll Surg. Dec 2015;221(6):1073-82 e1-3. doi:10.1016/j.jamcollsurg.2015.09.009
Lincoln YS, Guba EG. Naturalistic inquiry. Sage Publications; 1985:416 p.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006; 3(2):77-101. doi:10.1191/1478088706qp063oa
Schmutz KE, Wallace AS, Bristol AA, Johnson EP, Raaum SE. Hospital Discharge During COVID-19: The Role of Social Resources. Clin Nurs Res. May 2022;31(4):724-732. doi:10.1177/10547738221075760
Taupin D, Anderson TS, Merchant EA, et al. Preventability of 30-Day Hospital Revisits Following Admission with COVID-19 at an Academic Medical Center. Jt Comm J Qual Patient Saf. Nov 2021;47(11):696-703. doi:10.1016/j.jcjq.2021.08.011
Bobay KL, Jerofke TA, Weiss ME, Yakusheva O. Age-related differences in perception of quality of discharge teaching and readiness for hospital discharge. Geriatr Nurs. May-Jun 2010;31(3):178-87. doi:10.1016/j.gerinurse.2010.03.005
Howard-Anderson J, Busuttil A, Lonowski S, Vangala S, Afsar-Manesh N. From discharge to readmission: Understanding the process from the patient perspective. J Hosp Med. Jun 2016;11(6):407-12. doi:10.1002/jhm.2560
Lakhan P, Jones M, Wilson A, Gray LC. The Higher Care At Discharge Index (HCDI): identifying older patients at risk of requiring a higher level of care at discharge. Arch Gerontol Geriatr. Sep-Oct 2013;57(2):184-91. doi:10.1016/j.archger.2013.04.003

No competing interests reported.

Download PDF

Editorial decision: Major revision
19 Oct, 2023
Reviews received at journal
28 Sep, 2023
Reviewers agreed at journal
25 Sep, 2023
Reviewers invited by journal
25 Sep, 2023
Editor assigned by journal
25 Sep, 2023
Submission checks completed at journal
25 Sep, 2023
First submitted to journal
07 Sep, 2023

You are reading this latest preprint version

Impact of COVID-19 Visitation Policies and Hospital Capacity on Discharge Readiness in Medicine Patients

Status:

Version 1

Abstract

Background

Objective

Design

Participants

Main Measures

Key Results

Conclusions

Clinical Trials Registration:

Introduction

Methods

Measures

Setting and Sample

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1