Routine vs. On-Demand Discharge Planning Strategy in Intermediate-Risk Patients for Complex Discharge: a Cluster-Randomized, Multiple Crossover Trial

Abstract

Background: Early hospital discharge planning can help to reduce the length of stay and unplanned readmission in high-risk patients. Therefore, it is important to select patients who can benefit from a personalized discharge planning based on validated tools. The modified Blaylock Risk Assessment Screening Score (BRASS) is routinely used in the Molinette Hospital (Turin, Italy) to screen patients at high risk for discharge, but the effectiveness of the discharge planning is uncertain in intermediate-risk patients.

Objective: To evaluate the best strategy for discharge planning by the Continuity of Care Hospital Unit (CCHU) in intermediate-risk patients according to modified BRASS.

Design: Cluster-randomized, multiple crossover trial.

Participants: Adult patients admitted in the Medicine and Neurology departments of the Molinette Hospital in Turin, Italy, between June 2018 and May 2019 with a BRASS intermediate risk.

Interventions: A routine discharge planning strategy (RDP, Routine Discharge Plan), which involved the management of all intermediate-risk patients, was compared to an on-demand discharge planning strategy (DDP, on-Demand Discharge Planning), which involved only selected patients referred to the CCHU by ward staff.

Main measures: The primary outcome was the 90-day hospital readmission for any cause (HR90). Secondary outcomes included the prolonged length of stay (pLOS).

Key results: Eight hundred two patients (median age 79 years) were included (414 RDP and 388 DDP). Comparing RDP vs. DDP periods, HR90 was 27.6% and 27.3% (OR 1.01, 90%CI 0.76-1.33, p = 0.485); and pLOS was 47 (11.4%) and 40 (10.3%) (OR 1.24, 95%CI 0.72-2.13, p = 0.447), respectively.

Conclusions: This is one of the largest randomized study conducted to compare the effectiveness of two different hospital discharge planning strategies. In patients with intermediate risk of hospital discharge, a RDP offers no advantage over a DDP and results in an unnecessary increase in staff workload.

Trial registration: Clinicaltrials.gov: NCT03436940.

Keywords: cluster-randomized trial; continuity of care; discharge planning; hospital readmission.