NUR 409 Module 7 Project Three Unplanned Hospital Visits Example

Project Three: Unplanned Return Visits for COPD Within 30 Days of Discharge From 5 East

[Student Name]

Southern New Hampshire University

NUR 409: Strategies for Quality Improvement in Healthcare

Project Three

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Project Three: Unplanned Return Visits for COPD Within 30 Days of Discharge From 5 East

Readmissions have long been treated as a sign that something went wrong in the hand-off from hospital to home. A national analysis of Medicare claims found that almost one fifth of discharged beneficiaries, 19.6%, were rehospitalized within 30 days, and that for half of those rehospitalized after a medical stay there was no bill for a physician office visit in between (Jencks et al., 2009). This project examines unplanned return visits for chronic obstructive pulmonary disease (COPD) on 5 East, a composite medical unit. It argues that most of the unit's COPD returns trace to a thin transition, no early follow-up, no confirmed inhaler technique and no action plan, and that a nurse-led bundle addressing those gaps can reduce returns without waiting for system-wide change. All unit data are composite.

Why COPD and Why Unplanned Visits

COPD is one of the conditions included in the federal Hospital Readmissions Reduction Program, under which hospitals whose readmissions for selected conditions run higher than expected receive lower Medicare payments (Centers for Medicare & Medicaid Services, n.d.). For patients, a return visit usually means another exacerbation, more steroids and more time lost from home. This project counts both readmissions and emergency visits that ended in discharge, because counting readmissions alone can hide patients who come back through the emergency department and are sent home or placed in observation. The measure is the percentage of patients discharged from 5 East with a primary diagnosis of COPD exacerbation who had an unplanned emergency visit or inpatient readmission for any cause within 30 days.

Current Performance

Over 12 months, 5 East discharged 58 patients after a COPD exacerbation. Sixteen, or 28%, had an unplanned return within 30 days: 10 were readmitted and 6 were treated in the emergency department and sent home. Eleven of the 16 returns happened in the first 14 days. The unit's quality champion reviewed each case and called patients who agreed to talk. Of the 16, 11 had no follow-up appointment scheduled within 7 days of discharge, 9 had no documented inhaler technique check, 12 left without a written action plan, 5 reported problems obtaining home oxygen or nebulizer supplies and 4 described a social need, such as transportation or cost of medications, that affected their care after discharge.

Drivers of Return Visits

The case review points to four drivers. The first is the absence of early follow-up; most returns came in the first two weeks, when a visit could have caught a worsening exacerbation. The second is inhaler technique, which is often poor and rarely checked, so patients leave with devices they cannot use well. The third is the lack of a written action plan telling patients what to do when breathlessness increases and when to call rather than come in. The fourth is supply and social barriers, which a nurse cannot solve alone but can identify before discharge. These drivers match what hospitals themselves prioritize. In a 2026 multisite study preparing COPD transitions of care programs at 21 hospitals, participants most often chose follow-up visits after an emergency visit, education on inhaler technique, disease management and action plans, and pulmonary rehabilitation, while naming barriers such as staff time, training and patients' social needs (Akula et al., 2026).

Aim

Within nine months, 5 East will reduce unplanned 30-day return visits among patients discharged after a COPD exacerbation from 28% to 18% or lower, while ensuring that at least 90% of these patients leave with a follow-up appointment within 7 days, a documented inhaler technique check and a written action plan. The target reflects a meaningful reduction that the unit can influence through its own discharge process, while recognizing that some returns are driven by disease severity and will not be prevented by any transition bundle.

The Transitions Bundle

The plan is a five-part bundle, led by nurses and started on admission rather than on the day of discharge. First, a nurse checks inhaler technique with each device the patient will use at home, corrects errors and uses teach-back to confirm understanding, a method shown effective in most studies in a systematic review of its use (Talevski et al., 2020). Second, the nurse completes a written COPD action plan with the patient, describing usual symptoms, early warning signs and when to take rescue medication, call the clinic or seek emergency care. Third, the unit clerk schedules a follow-up appointment within 7 days before discharge, with the date on the discharge paperwork. Fourth, a nurse calls each patient within 48 hours to ask about breathing, medications, supplies and the appointment. Fifth, patients are screened for social needs and referred to case management and, when eligible, to pulmonary rehabilitation.

Measures and Testing

The outcome measure is the 30-day unplanned return rate, reported monthly. Process measures are the share of COPD discharges with a follow-up appointment within 7 days, a documented inhaler technique check, a written action plan and a completed 48-hour call. A balancing measure will track length of stay, since adding discharge tasks could delay discharges if they are left to the last day. The bundle will be introduced through small tests of change, beginning with the inhaler check and action plan on day shift for two weeks, then adding the scheduled appointment and the call. Because monthly numbers are small, the team will review results on a run chart and look for sustained shifts rather than reacting to single months.

Limits

The unit sees fewer than five COPD discharges a month, so the outcome rate will fluctuate, and a real improvement may take months to show. Returns to other hospitals may be missed unless the health information exchange is checked. Some returns reflect advanced disease that no discharge bundle can prevent. An official workshop report from the American Thoracic Society reviewed strategies for reducing COPD readmissions and the gaps in evidence behind them (Press et al., 2019), a reminder that the bundle should be treated as a test, not a guarantee.

Conclusion

More than a quarter of patients discharged from 5 East after a COPD exacerbation come back within 30 days, most within two weeks and most without the follow-up, technique check or action plan that might have kept them home. A nurse-led bundle that starts on admission addresses those gaps directly and can be tested on the unit now, with process measures that show whether it is happening and an outcome measure that shows whether it is working.

References

Akula, M., Erwin, K., Traeger, L., Pick, H., Gao, F., Damschroder, L., & Press, V. G. (2026). Contextual assessments for chronic obstructive pulmonary disease transition of care bundle implementation planning for the Reduce REVISITS study: Rapid sequential explanatory mixed methods approach. JMIR Human Factors, 13, Article e82078. https://doi.org/10.2196/82078

Centers for Medicare & Medicaid Services. (n.d.). Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine, 360(14), 1418-1428. https://doi.org/10.1056/NEJMsa0803563

Press, V. G., Au, D. H., Bourbeau, J., Dransfield, M. T., Gershon, A. S., Krishnan, J. A., Mularski, R. A., Sciurba, F. C., Sullivan, J., & Feemster, L. C. (2019). Reducing chronic obstructive pulmonary disease hospital readmissions: An official American Thoracic Society workshop report. Annals of the American Thoracic Society, 16(2), 161-170. https://doi.org/10.1513/AnnalsATS.201811-755WS

Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLOS ONE, 15(4), Article e0231350. https://doi.org/10.1371/journal.pone.0231350