Utilizing a Nurse Discharge Navigator to Reduce Readmissions for Hospitalized Patients With Sepsis: A Quality Improvement Feasibility Study.

IF 0.9 Q4 HEALTH CARE SCIENCES & SERVICES

Professional Case Management Pub Date : 2025-07-23 DOI:10.1097/NCM.0000000000000823

Marta Pruitt, Abby Matusik, Neelam Patel, Kathryn Kreider

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引用次数: 0

Abstract

Purpose/objectives: The purpose of this project was to evaluate the impact of a nurse discharge navigator implementing an education and structured outpatient follow-up program on reducing 30-day readmissions for adult patients with sepsis.

Primary practice setting: This project was implemented at an 847-bed academic hospital in the southeastern United States.

Findings/conclusions: Patient capture in the study was poor, driven by high rates of cancer diagnoses, comfort-directed care, and frequent discharges to postacute care. Readmission rates for patients receiving the full intervention (n = 16) were 25% (n = 4). Overall readmission rates for patients with sepsis in 2024 were 13.3% (n = 61). The outcomes of this project were influenced by the advanced comorbidities of the participants.

Implications for case management practice: Case management of patients with sepsis should be comprehensive. Caregivers should be involved early to initiate education on the disease process, have clear communication with the follow-up team, and involve close, structured follow-up that can be adapted to the postacute care setting. One promising area for improvement of this intervention would be the inclusion of a Hospital at Home program as a transition program to the transition clinic.

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利用护士出院导航仪减少脓毒症住院患者再入院：一项质量改进可行性研究。

目的/目的：本项目的目的是评估护士出院导导员实施教育和结构化门诊随访计划对减少成人脓毒症患者30天再入院的影响。主要实践环境：本项目在美国东南部一家拥有847张床位的学术医院实施。研究结果/结论：由于癌症诊断率高、舒适指导的护理和频繁的急性后护理，研究中的患者捕获很差。接受全面干预的患者（n = 16）再入院率为25% （n = 4）。2024年脓毒症患者的总再入院率为13.3% （n = 61）。该项目的结果受到参与者的晚期合并症的影响。对病例管理实践的启示：脓毒症患者的病例管理应该是全面的。护理人员应尽早参与，以启动疾病过程的教育，与随访团队进行明确的沟通，并进行密切的、结构化的随访，以适应急性后护理环境。改善这种干预的一个有希望的领域是将家庭医院项目作为过渡诊所的过渡项目。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Professional Case Management HEALTH CARE SCIENCES & SERVICES-

CiteScore

0.90

自引率

26.70%

发文量

113

期刊介绍： Professional Case Management: The Leader in Evidence-Based Practice is a peer-reviewed, contemporary journal that crosses all case management settings. The Journal features best practices and industry benchmarks for the professional case manager and also features hands-on information for case managers new to the specialty. Articles focus on the coordination of services, management of payer issues, population- and disease-specific aspects of patient care, efficient use of resources, improving the quality of care/patient safety, data and outcomes analysis, and patient advocacy. The Journal provides practical, hands-on information for day-to-day activities, as well as cutting-edge research.