Author ORCID Identifier


Date Available


Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Karen Stefaniak

Clinical Mentor

Dr. George Russell

Committee Member

Dr. Tukea Talbert


Preventing Patient Readmission

Background and Review of Literature: Communication is the foundation of patient safety. As patients move from the acute to post-acute care setting, risk for insufficient communication rises. Research demonstrates a vast array of communication hand-off tools currently exist for and between different care arenas. No one tool has been standardized for patients transitioning from acute to post-acute care settings. The Institute of Medicine (IOM) and The Joint Commission (TJC) have published multiple documents discussing communication plagues within health care resulting in readmission.

Purpose: The purpose of this project is multifaceted: 1) identifying current nursing communication practices between a large quaternary care, academic medical center and post-acute in-patient physical rehabilitation hospital; 2) capture nursing perceptions of transitional care communications quality and timeliness; 3) hand-off communication tool creation; and 4) pilot implementation of communication tool with analysis of pre- and post-project findings.

Methods: This is a quasi-experimental research approach using quantitative data for two distinct groups. Retrospective data comparative analysis evaluating patient readmissions was obtained at the start of the project to determine baseline readmission rate for previous three-months followed by one-month post-implementation medical record review of patients transferred from an academic medical center to inpatient rehabilitation hospital (IRF). Patients were included based on age and discharged location (age18 years or greater; only transferred to Methodist Rehabilitation Hospital). Exclusion criteria included less than 18 years of age, transferred to location other than identified IRF, discharged against medical advice, deceased during IRF admission, non-cooperative or non-compliant with care or admission status other than inpatient.

Second distinct group was registered nurses surveyed within one-month pre-implementation of new hand-off communication tool and immediately post-project completion for comparative analysis of survey responses related to nursing perception of hand-off communication processes: 1) time it takes to complete hand-off communication process; 2) communication elements are appropriate to prevent patient readmission; 3) process of patient hand-off is consistent (no variation from patient-to-patient); 4) identifies use of a current patient hand-off process; 5) identifies if there is a personal belief hand-off communication prevents patient readmission; and 6) if the receiving facility has questions concerning the patient post-transfer, how does the nurse respond to these queries. Inclusions were registered nurses with any level of nursing degree, working on trauma or neurology type unit or in care coordination. Exclusions were those employed less than 90-days.

Implementation Plan/Procedure: The Iowa Evidence-Based Model was utilized to guide implementation and evaluation of the project. Results: The study identified statistically significant difference in readmission events occurring in patients transitioned from acute to post-acute IRF when nursing hand-off communication is utilized, standardized and consistent.

Conclusion: A 22% reduction in patient readmission is identified between patient populations of pre- and post-project implementation. This indicates standardized hand-off nursing communication statistically impacts (reduces) readmission in patients when information is shared actively and timely between organizations.