NU806 Unit 3 DNP Discussion Section Example

A Change Delivered, a Benefit Likely but Unproven: A Unit 3 Discussion Section for an Insulin Discharge Readiness Project

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Purdue University Global

NU806: DNP Project III

Unit 3 Discussion Section

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[Date]

The hospital, units and results are composite and illustrative; the studies compared are real.

Principal Findings

The project achieved its delivery aims more fully than its outcome aim. Four in five patients received every part of the bundle, where the baseline audit had found no single part documented for even 60 percent of patients, and the pen measure met the rule for a sustained shift. The outcome moved in the expected direction by about five percentage points, which is roughly the size the aim set, but the comparison did not reach statistical significance, and the interval allows for anything from a large benefit to a small harm. Balancing measures showed no slower discharges and no rise in lows.

The honest summary is that the bundle was delivered reliably and safely, and that the outcome result is consistent with benefit but does not establish it.

A five-point fall that might be chance is still a five-point fall; the work is to say both things in the same sentence.

Why the Outcome Result Is Uncertain

The main reason is size. A two-period comparison with 80 percent power to find a fall of this size would need close to 600 patients on each side, roughly four times what the project had after the bundle and nearly three times what it had before. The project was designed as an improvement for one hospital, not as a study powered to prove an effect, and the result reflects that. A second reason is time. Units started at different points and changes were made throughout the first months, so the earliest patients received a less complete bundle than the later ones.

Comparison With Published Work

Published studies point the same way, with changes of a broadly similar size. Healy et al. (2013), in a retrospective cohort, found that inpatient diabetes education was associated with lower odds of 30-day readmission among patients with poor control, an adjusted odds ratio of 0.66. Drincic et al. (2017) reported a fall in 30-day readmission for patients with diabetes from 20.1 to 17.6 percent after a tiered educator and resource nurse program across a far larger hospital, a smaller absolute change on a much larger base. This project's resource nurse model drew directly on that study, and its absolute change is larger, though uncertain.

Wexler et al. (2012) found the benefit of inpatient management and education concentrated in patients newly discharged on insulin, the population of this project, which may explain why a bundle aimed only at new insulin starters could show a larger effect than broader programs.

Two findings fit published work less comfortably. Follow-up contact by day three reached 93 percent of patients, yet five of the 13 returns occurred in the first week. Jayakody et al. (2016) found telephone follow-up effective only when combined with support before discharge, and this project's experience suggests that early contact finds problems but does not by itself prevent every early return. And the payer gap persisted: Medicaid and uninsured patients received all five parts less often and returned more than twice as often. Stedge et al. (2023) found that delivering medicines before discharge helped most when cost was also addressed, and the bundle's bridge supply reached only patients whose coverage was pending at discharge, not those whose copays later proved unaffordable.

Limitations

Design. Comparing a year before with the months after leaves room for anything else that changed in the hospital over the same period, from staffing to the patient mix. The staggered starts help, but the outcome chart showed no clear signal at each unit's start, so the design's added strength was not realized for the outcome.

Measurement. Returns were counted only at this hospital, so patients who went elsewhere were missed in both periods. If the bundle's check-ins sent more patients back to this hospital rather than elsewhere, the measured benefit would be understated; the reverse is also possible.

Documentation. Process measures depend on documentation, checked by audit but not observed directly after the first weeks.

Adaptation. The bundle changed eleven times, all within its core functions. The evaluation describes a bundle as it evolved, and the final form is stronger than the one most early patients received.

Generalizability. One regional hospital, one educator and a supportive executive sponsor may not resemble other settings.

What the Delivery Result Means

It would be easy to treat the delivery result as a means to the outcome and nothing more. It is a finding in its own right. Before the project, the parts of the bundle depended on which nurse happened to be assigned, and the audit found most of them missing for most patients. After it, they reached most patients on units as different as cardiac step-down and oncology, at nights and on weekends, without a second educator. That reliability came from changes to systems, the pharmacy schedule, the order set, the discharge fields and the resource nurse role, rather than from asking nurses to try harder. Proving that reliable delivery lowers returns will take more patients than one hospital discharges in a year. Showing that reliable delivery is achievable was within this project's reach, and it was achieved.

Implications for Practice

For this hospital, the findings support keeping the bundle on all eight units, because it is delivered reliably, costs little beyond existing staff time and shows no harm, and because its likely benefit matches the published evidence. Measurement should continue for at least a year, which would bring the comparison close to the size needed to judge the outcome. Two changes deserve priority: addressing medication cost after discharge for Medicaid and uninsured patients, and reviewing with hospitalists whether simpler discharge regimens would reduce the uncertainty that correction scales caused.

For other hospitals, the project offers a delivery model rather than proof of effect: a resource nurse on each unit, pens dispensed on the first insulin day, a supervised dose the evening before discharge and two-way texts in place of most educator calls.

Recommendations for Further Work

A multi-hospital evaluation with enough patients to test the outcome would answer the question this project could not. Within the hospital, the next improvement cycle should target the first week after discharge and the payer gap, since that is where the remaining returns concentrate.

Conclusion

The bundle reached patients reliably, safely and at modest cost, and returns fell by an amount consistent with published work but not large enough, on these numbers, to rule out chance. Keeping the bundle, continuing to measure and directing the next cycle at cost and the first week home are the actions the evidence supports.

References

Drincic, A., Pfeffer, E., Luo, J., & Goldner, W. S. (2017). The effect of diabetes case management and Diabetes Resource Nurse program on readmissions of patients with diabetes mellitus. Journal of Clinical & Translational Endocrinology, 8, 29-34. https://doi.org/10.1016/j.jcte.2017.03.003

Healy, S. J., Black, D., Harris, C., Lorenz, A., & Dungan, K. M. (2013). Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care, 36(10), 2960-2967. https://doi.org/10.2337/dc13-0108

Jayakody, A., Bryant, J., Carey, M., Hobden, B., Dodd, N., & Sanson-Fisher, R. (2016). Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: A systematic review. BMC Health Services Research, 16, 403. https://doi.org/10.1186/s12913-016-1650-9

Stedge, B., Xu, J., Kubes, J. N., Han, E., Russie, C., Woods, L., & O'Donnell, C. (2023). Meds to beds at hospital discharge improves medication adherence and readmission rates in select populations. Southern Medical Journal, 116(3), 247-254. https://doi.org/10.14423/SMJ.0000000000001532

Wexler, D. J., Beauharnais, C. C., Regan, S., Nathan, D. M., Cagliero, E., & Larkin, M. E. (2012). Impact of inpatient diabetes management, education, and improved discharge transition on glycemic control 12 months after discharge. Diabetes Research and Clinical Practice, 98(2), 249-256. https://doi.org/10.1016/j.diabres.2012.09.016