The course of readmission in frail older cardiac patients.
Corinne J Rijpkema, Lotte Verweij, Patricia Jepma and 4 others
PMID 33739473WHAT IT FOUND
Across five older cardiac patients readmitted after discharge support, visiting nurses and physical therapists had not seen the deterioration in three cases.
Infrequent visits and incomplete records limited detection, and rehabilitation goals sometimes did not match patient expectations.
Key findings
01The CCB caregivers were not involved in observing the health deteriorations that led to readmission in the other three cases; informal caregivers, general practitioners or regular home-care nurses were involved instead.
02Low frequency of home visits and inconsistent reporting of vital signs in the medical record limited continuity and early detection of deterioration.
03Patients and informal caregivers preferred to contact formal caregivers in the existing network, so CCB caregivers were not informed when health deteriorated.
STILL TO COME
How it was doneWhat they foundWhat it means for PTsWhat it means for RNs
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What it does not show
Only five cases were studied, so it describes those patients' and caregivers' experiences, not a pattern for all older cardiac patients. Patients and caregivers sometimes had difficulty remembering details, and one patient could not be interviewed because of poor health and hospice admission. Not all CCB caregivers reported care activities comprehensively in the medical record, which made it hard to reconstruct what happened. Formal caregivers from the existing care systems were not interviewed, so the study may miss their perspective. Cases were selected only if they had unplanned readmission and received the post-clinical phase, and interviews were up to six months after randomization to reduce recall bias.
Declared interests
No conflict of interest has been declared by the authors.
The easy way to misread this
Do not use these five cases as evidence about whether the CCB program prevents readmission. It reports perspectives and process, not an effectiveness comparison. The program included geriatric assessment, integrated care planning, discharge handover, community-nurse home visits, medication reconciliation with pharmacist assistance, and home-based physical therapy, so the contribution of any single component cannot be separated.