Effectiveness of planning hospital discharge and follow-up in primary care for patients with chronic obstructive pulmonary disease: research protocol

P>Title. Effectiveness of planning hospital discharge and follow-up in primary care for patients with chronic obstructive pulmonary disease: research protocol. Aim. To evaluate the effectiveness of a protocolized intervention for hospital discharge and follow-up planning for primary care patients with chronic obstructive pulmonary disease. Background. Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. These patients suffer from high rates of exacerbation and hospital readmission due to active problems at the time of hospital discharge. Methods. A quasi-experimental design will be adopted, with a control group and pseudo-randomized by services (protocol approved in 2006). Patients with pulmonary disease admitted to two tertiary-level public hospitals in Spain and their local healthcare centres will be recruited. The outcome variables will be readmission rate and patient satisfaction with nursing care provided. 48 hours after admission, both groups will be evaluated by specialist coordinating nurses, using validated scales. At the hospital, a coordinating nurse will visit each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, and explain treatment. In addition, the visits will be used to identify care problems and needs, and to facilitate communication between professionals. 24 hours after discharge, the coordinating nurses will inform the primary care nurses about patient discharge and nursing care planning. The two nurses will make the first home visit together. There will be follow-up phone calls at 2, 6, 12 and 24 weeks after discharge. Discussion. The characteristics of patients with this pulmonary disease make it necessary to include them in hospital discharge planning programmes using coordinating nurses.