Post-discharge telephone follow-up calls to patients with chronic obstructive pulmonary disease by primary care nurses: a best practice implementation project.

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex health problem, with important repercussions for patients and their families. Interventions need to be improved to prevent exacerbations and reduce high readmission and mortality rates. Evidence suggests that including a telephone follow-up (TFU) call in discharge plans could improve outcomes in patients with a chronic disease.

Objectives: This project aimed to improve how primary care nurses in Gran Canaria, Spain, followed up COPD patients after hospital discharge.

Methods: This project was guided by the JBI Evidence Implementation Framework, which includes the JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) method. The JBI approach uses audit, feedback, and re-audit to promote evidence-based health care.

Results: A baseline audit was conducted to compare current practices against best practices. Five barriers to best practices were identified and improvement strategies were developed. The follow-up audit revealed 100% compliance for Criteria 1 and 2, which related to COPD patients having a discharge plan and that plan including TFU. There was a 4.88% improvement for both Criteria 3 and 4, which involved the TFU being prompt and using a validated clinical questionnaire. Following project implementation, the 30-day readmission rate increased from 2.78% to 4.88% but the 30-day emergency room presentation rate decreased from 25% to 9.76%.

Conclusions: The practice changes were partly achieved, but further strategies are needed to achieve full compliance. Educational programs are necessary when conducting improvement projects. Chances of success increase when decisions about hospital discharge involve both the hospital and the primary care service.

Spanish abstract: http://links.lww.com/IJEBH/A296.