Association between inpatient clinical nursing acuity and 30-day rehospitalization among hospitalized patients with advanced cancer.
Authors: Lage Daniel E , Kyle Michael Anne , Grasso Antigone , Feilteau Charlene , Hernand Max G , Schmelkin Alane , Keating Nancy Lynn , Greer Joseph A. , El-Jawahri Areej , Nipp Ryan David , Temel Jennifer S. 
Published: June 2023

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Background: Half of patients with advanced cancer experience multiple hospital readmissions, which are burdensome to patients and their family members. During hospitalization, nurses provide assistance with medication administration, activities of daily living (ADLs), and other care needs. However, it is not known how nursing support required during hospitalization may relate to hospital readmissions. Using data from a post-discharge supportive care trial, we analyzed the association between nursing acuity on day of discharge to home and 30-day rehospitalization among patients with advanced cancer. Methods: The data for this exploratory analysis came from a single-arm pilot trial (n=54) of a nurse practitioner-led supportive care telehealth intervention at Massachusetts General Hospital (MGH). We enrolled English-speaking adults with advanced breast, gastrointestinal, genitourinary, or thoracic cancers who had an unplanned hospitalization and were being discharged home without hospice. MGH uses the Harris Healthcare AcuityPlus workload and productivity system to measure patients’ need for nursing care twice daily, in order to define nurse staffing levels. AcuityPlus groups patients into six levels of acuity (1=0-5 hours; 2=5-7 hours; 3=7-10 hours; 4=10-14 hours; 5=14-20 hours; 6=20+ hours). We conducted chart reviews to determine 30-day hospital readmission rates and analyzed the last AcuityPlus assessment before hospital discharge. We described rates of 30-day hospital readmissions by nursing acuity level. Results: From 01/07/21 to 05/28/21, we enrolled 54 patients (median age=65.0 years; 59.3% and 22.2% had advanced gastrointestinal or thoracic cancers, respectively). On day of discharge, no patients were classified as acuity level 1, while 25.9% of patients were classified as acuity level 2. 53.7% were in acuity level 3 and 20.4% were in acuity levels 4-6. Further, at discharge, 64.8% of patients received partial or extended assistance with ADLs, and 53.7% were assessed at least every 2 hours. At 30 days, 10 (18.5%) patients were readmitted to the hospital, all of whom were in acuity category 3 or higher on the day of discharge. No patients in acuity level 2 were readmitted. Conclusions: In this cohort of hospitalized patients with advanced cancer enrolled in a post-discharge supportive care study, overall need for nursing care, ADL support, and assessment was high, with over 70% of patients receiving at least 7 hours of nursing care on the day of discharge. While some nursing care received was influenced by inpatient nursing protocols, all readmitted patients had high nursing needs at discharge. These results support further study in larger cohorts of the relationship between inpatient nursing needs and likelihood of readmission in hospitalized patients with advanced cancer to improve support at home for recently hospitalized patients. Clinical trial information: NCT04640714 .