Date of Award

Summer 9-4-2018

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Joseph Burkard, DNSc, CRNA, AACN


Evidence-based Strategies for Reducing Post-discharge E.R. Visits and Patient Initiated Calls in the post Craniotomy Population

Homira Feely, NP

Katherine Curran, BSN

Joseph Burkard, DNSc, CRNA

University of San Diego


Health-care professionals are generally compassionate and well-meaning, but the infrastructure in which they function often has made the continuum of care between hospitals, outpatient settings and patients’ homes far from seamless. The result is a persistently high rate of emergency room visits and hospital readmissions within 30 days of a patient’s discharge – an avoidable pattern that has cost the U.S. health system tens of billions of dollars over the decades.

Using an evidence-based approach for our new project, we have found significant success in sharply reducing neurosurgery patients’ non-essential, post-discharge phone calls and E.R. visits.

We have focused on three crucial time points with patients and their caregivers: education during pre-op clinic visits, followed by a phone call 24 hour after hospital discharge and finally another call 72 hours after discharge. These simple, clear, proactive steps can be adopted by hospitals and outpatient providers across the country in a variety of medical disciplines.


Post-cranial surgery patients have multiple health concerns, including those that can lead to emergency-room visits after discharge that could have been negated with key follow-up care measures. These individuals are part of a broad and ongoing challenge that has been long documented by various levels of research. Even though prominent medical organizations and government agencies have highlighted the problem, and despite Medicare’s relatively recent imposition of a financial penalty for preventable readmissions, the issue is far from resolved. The preventable post-discharge troubles largely stem from lack of – or poor – coordination between a patient’s medical providers. Experts have identified the following challenges as prime reasons for avoidable visits to the emergency room:

  • Premature discharge from the hospital.
  • Insufficient or unclear instructions regarding what medications a patient needs to take, the appropriate dosing, which side effects are common and which necessitate prompt attention by a medical professional, and any potentially troublesome interactions between drugs prescribed in the hospital and those the patient was already taking upon admission.
  • Inadequate or no information about whom a patient should call with post-discharge treatment questions; this dearth of details can spur certain people to visit the emergency room for issues that can be managed by a primary-care physician, home health nurse, physical therapist, etc.
  • Substandard discussion with a patient’s family members or other caregivers about post-discharge care.
  • Subpar, minimal or even nonexistent communication between a patient’s hospital staff and his/her primary-care providers on issues ranging from the next required medical appointments, to rehabilitation needs, to whether the patient has help at home for daily routines.


The project described in this abstract was launched in December 2016, January and February of 2017 with collection of pre implementation data. Implementation of its main steps began in December of 2017, January and February of 2018 and test interaction with patients and data accumulation is expected to finish by March. During patients’ pre-op clinic visits, we are educating them about what to expect before, during and after their brain surgeries. This includes going over details about their home environment, their caregiver(s), their transportation needs, the likely process for their post-discharge home health care, infection-control efforts, what symptoms are clear signs for needing emergency care (vs. symptoms that are part of the normal recovery process), what phone numbers are best to call if they have additional questions that have not been addressed by me or other staff members, etc.

Using a daily list of newly discharged neurosurgery patients, we are making telephone calls to those individuals around 24 hours after their hospital departure, and then again at the 72-hour mark. In particular, we are relying on a standardized questionnaire and employing the 5 A’s Behavior Change Model: assess, advice, agree, assist and arrange. We are assessing each patient’s pain level and, with his/her collaboration, set a goal for what pain level is expected and manageable. We also discuss the status of home health nursing, plus what to anticipate for the patient’s next medical appointments.


The positive aspects of this project are that it is manageable, involving only small team that already works together closely; that it has well-defined protocols; and that its results can be quantified. Effectiveness is being measured by the number of patients’ post-discharge phone calls and visits to the emergency room.

So far, we have seen reductions in both of these categories. Our goal is to achieve a 30 percent reduction in patients’ post-discharge E.R. visits during the three-month project period, as compared with the same three months from the previous year. Another central objective is to lower the number of patients’ post-discharge phone calls by 50 percent during the same project duration.


Improved pre-operative education along with well-timed post-discharge phone calls should reduce ER visits and patient’s calls and improve satisfaction. Widespread adoption of this proactive form of outreach can better bridge the current gap between hospital and home care, and the net result will be not only improved continuity of care and thus long-term outcomes, but also greater assurance and satisfaction on the part of patients.

Included in

Nursing Commons