ADT Nurse

1. Kelly Hof
Cohort 1
10/7/14

Admission, Discharge, Teaching Nurse to Improve Safety and Satisfaction
Background
"Discharge planning and patient teaching are important for quality patient care"
(Lane, Jackson, Odom, Canella, & Hinshaw, 2009, p.148). Admissions and discharges
are tasks that "normally disrupt the continuity of care on patient units" (Giangiulio,
Aurilio, Baker, Brienza, Moss, & Twinem, 2008, p. 61). 6 Central is a floor that
experiences high patient turnover. Each nurse cares for the mother/baby pair, which is
referred to as a couplet. On a quiet day, a nurse may have 2 to 3 couplets. On a busy day,
a nurse may have 3 to 5 couplets. Sometimes a couplet might include a mother with a set
of twins, in which case the nurse would care for the mother and both babies. Couplets
stay between 2 to 4 nights depending on the type of birth and the mother’s insurance
coverage. This means that nurses can expect at least one admission per shift, and they
must prepare for at least one discharge every shift. Day nurses can expect to discharge 1
to 2 couplets and admit 1 to 2 couplets per shift. This means they can potentially
document on 6 to 12 patients per shift, or more if twins are involved.
6 Central is also a teaching-intensive floor. Each mother, especially a first time
mother, requires education on how to care for herself and the baby. Each mother receives
a packet of information with 28 topics that the nurse must review with the mom and sign.
In addition, the nurse must explain the Code Pink protocol and clarify with the mother
which hospital staff may transport the baby, have the mother watch the Shaken Baby
Shattered Promise video and sign a form that goes to New York state, review the Pain
Management education packet and document the teaching in Eclypsis, and physically
assist the mother to breastfeed. With all the time spent in teaching, admissions, and
discharges, patient care can become disjointed, and discharge phone calls are frequently
neglected. Studies show that discharge phone calls improve patient satisfaction ratings
(Dudas, Bookwalter, Kerr, & Pantilat, 2002. p. 241-242). 6 Central may benefit from a
team of RNs that are specifically assigned to help with admissions, discharges, patient
teaching, and discharge phone calls.

2. Implications to Practice
HCAHPS patient satisfaction scores for 6 Central are below national average for
the following topics: Communication with Nursing, Response of Hospital Staff, Pain
Management, and Discharge Information (HCAHPS January 1-June 30, 2014). Having
nurses specifically responsible for helping with admissions, discharges, discharge phone
calls, and patient teaching could help free up floor nurses to spend more time with
patients. In hospitals that have created this position, it is often referred to as the “ADT
nurse”, which stands for either Admission, Discharge, Transfer nurse or Admission,
Discharge, Teaching nurse. For the purposes of this proposal, ADT will refer to
Admission, Discharge, Teaching. This position could improve HCAHPS scores for the
above-mentioned topics because floor nurses would have more time to communicate with
their patients, respond to their calls, help with breastfeeding, and attend to pain
management. The ADT nurse would be spending time helping to admit patients,
complete discharge teaching and paperwork, and make discharge phone calls, which
should also improve patient satisfaction scores.
Nurses on 6 Central agree that to go through every topic in the Mother/Newborn
Educational/Discharge Instructions packet, the quickest that it can be done without any
questions from the patient is about 20 minutes. Allowing for questions, this can take an
hour or more. A survey of nurses on the floor reveals that admitting a couplet takes at
least 15 minutes to get the patients settled, and another 10 to 15 minutes to document.
Discharges take at least 25 minutes per couplet, plus 10 to 15 minutes for documentation,
and if the teaching packet is not completed, it can take at least an additional 20 minutes if
the patient has no questions.
Having more time to attend to patients is also important for patient safety.
Although these patients are considered to be well patients, there are risks associated with
post-partum mothers and newborn babies. Mothers are at risk for hemorrhage, anemia,
thrombosis, infection, pre-eclampsia/eclampsia, and falls. In addition to healthy
mothers, nurses on 6 Central care for mothers who experience gestational diabetes,
gestational hypertension, or those who have a history of chronic diabetes and/or
hypertension. 6 Central nurses also care for mothers who are on Magnesium for pre-
eclampsia, and those who require blood transfusions. Healthy newborns are at risk for

3. low blood sugar and high bilirubin, and nurses on 6 Central also care for babies that are
born as early as 35 weeks, and babies who are small or large for gestational age who
require blood glucose monitoring. Having ADT nurses helping with admissions,
discharges, teaching, and discharge phone calls would increase the amount of time that
floor nurses spend with their patients, which is especially important for patient safety.

Evidence
In all studies reviewed, implementation of an ADT nurse increased patient
satisfaction (Giangiulio et al. 2008, p. 79; Kirkbride, Floyd, Tate, & Wendler, 2012, p.
345; Spiva & Johnson, 2012, p. 91). A new admission can create "competing priorities"
(Kirkbride, Floyd, Tate, & Wendler, 2012, p. 345) resulting in disruption
and "fragmentation of patient care" (Lane, Jackson, Odom, Cannella, & Hinshaw, 2009,
p. 148). This can cause the admission process to become unnecessarily time-consuming
and lead to decreased patient satisfaction (Kirkbride, Floyd, Tate, & Wendler, 2012, p.
345). The ADT position allowed nurses to have more time engaging in direct care of
patients, which lead to increased patient satisfaction (Spiva & Johnson, 2012, p. 89,
92). In a 2009 case study by the Health Care Advisory Board, the implementation of
nurses who were dedicated to admissions and discharges made patients and their families
feel "calmer and more satisfied" (Kirkbride, Floyd, Tate, & Wendler, 2012, p. 345,
352). Patient satisfaction is especially important on an OB unit because according to the
U.S. Department of Labor statistics, "women make approximately 80 percent of health
care decisions for their families", which means that if a woman is satisfied with her
experience on the OB unit, she is more likely to bring her family back to that hospital for
care in the future ("Fact sheet: General, " 2013). In addition, "females of all ages
accounted for 57% of all expenses incurred at doctors' offices in 2011", so it makes
financial sense to keep mothers happy since they potentially bring in the most revenue
("Fact sheet: General, " 2013).
"Admissions and discharges may create stress for nurses and disjointed delivery
of care" (Lane, Jackson, Odom, Cannella, & Hinshaw, 2009, p. 148). Stressors such as
these, combined with the “inability to adequately meet the needs of patients have been
identified as nurse dissatisfiers” (Lane, Jackson, Odom, Cannella, & Hinshaw, 2009, p.

4. 148). In all studies reviewed, implementation of an ADT position increased nurse
satisfaction (Giangiulio et al. 2008, p. 70; Lane, Jackson, Odom, Cannella, & Hinshaw,
2009, p. 150; Kirkbride, Flowyd, Tate, & Wendler, 2012, p. 344; Spiva & Johnson, 2012,
p. 92). Prior to the creation of the ADT position, "nurses indicated that a majority of their
time was spent completing paperwork" (Spiva & Johnson, 2012, p. 89). The ADT
position "steadied workflow processes for nurses" (Kirkbride, Floyd, Tate, & Wendler,
2012, p. 344) "decreased the time nurses spent on paperwork", increased the time nurses
spent with patients, improved staffing during admissions, transfers, and discharges, and
increased nurses' job enjoyment (Spiva & Johnson, 2012, p. 91). "Nurses reported that
they no longer felt that they provided disjointed, interrupted care to their other assigned
patients each time a new admission arrived on their unit" (Giangiulio et al. 2008, p.
68). Lane, Jackson, Odom, Cannella, & Hinshaw (2009) reported that after the ADT
position was created nurses reported a "25% increase in job enjoyment", 38% more
nurses reported they "had enough time with patients", 100% of nurses reported that unit
admissions were not affected by inadequate staffing, and 25% more nurses plan to remain
on the unit (p. 149).
An additional advantage to the ADT nurse position is retention of older nurses
who may otherwise retire. In a survey of nurses over 50 years old, the majority
“described bedside nursing as physically and mentally exhausting,” and they suggested
creating “a less physically demanding” ADT nursing position (Spiva & Johnson, 2012, p.
89). In creating this position, "job opportunities were provided to older nurses that focus
on the nurses' knowledge, skill, and experience but with less physical demands associated
with direct bedside nursing" (Spiva & Johnson, 2012, p. 92).
The ADT position increased nurse productivity, saving time across all studies
(Giangiulio et al. 2008, p. 63; Kirkbride, Floyd, Tate, & Wendler, 2012, p. 345; Lane,
Jackson, Odom, Cannella, & Hinshaw, 2009, p. 149-150; Spiva & Johnson, 2012, p. 91).
In one hospital, the position "reduced each unit nurse's workload by 1 hour 12 minutes
per day (based on an average of 1.5 hours for admissions and 0.5 hours for discharges)"
(Lane, Jackson, Odom, Cannella, & Hinshaw, 2009, p. 149-150). In another hospital,
admission time was reduced by "20-40 minutes, saving $64,000 per year" (Giangiulio et
al. 2008, p. 63). A third hospital reduced admission time by 33 minutes (Spiva &

5. Johnson, 2012, p. 91). The Health Care Advisory Board noted a reduction in "the time
required for the admission by approximately half" (Kirkbride, Floyd, Tate, & Wendler,
2012, p. 345).
Studies have shown an association between "increased mortality and high patient
turnover" (Needleman et al. 2011, p. ). Admissions and discharges increase demands on
nurses, (Kirkbride, Floyd, Tate, & Wendler, 2012, p. 345), impair "nurses' surveillance of
patients", and increase the risk of adverse events (Needleman et al. 2011, p. 2). The ADT
nurse position in many cases has had a positive impact on nursing workflow and patient
safety (Kirkbride, Floyd, Tate, & Wendler, 2012, p. 344). In one hospital, "on several
occasions, the AD nurse assessed and intervened on patients who were deteriorating
rapidly" (Spiva & Johnson, 2012, p. 92). In several studies, with the implementation of
the ADT nurse role, improvements were noted in nursing documentation and medication
reconciliation (Lane, Jackson, Odom, Cannella, & Hinshaw, 2009, p. 150; Spiva &
Johnson, 2012, p. 92).
"Staffing projection models rarely account for the effect on workload of
admissions, discharges, and transfers" (Needleman et al. 2011, p. 2). The Institute for
Healthcare Improvement points out that staffing isn't just about sheer numbers, but
recommends strategic staffing to "improve patient flow" and stresses that "the admission
process needs to be completed with the focused attention of a registered nurse (RN) in a
timely fashion", as does the discharge process (Kirkbride, Floyd, Tate, & Wendler, 2012,
p. 344-345). When staffing is designed to improve patient flow, benefits include "better
clinical outcomes, improved patient safety, and improved financial
performance" (Kirkbride, Floyd, Tate, & Wendler, 2012, p. 345).

Recommendations
After reviewing the literature, I recommend the consideration of staffing RNs to
specifically help with admissions, discharges, teaching, and discharge phone calls.
Whether this is done on a day-to-day/PRN basis after considering the number of
admissions and discharges that are expected during the day, or whether certain nurses are
employed to come in daily to assist with these tasks remains to be evaluated. Due to the
amount of teaching and the number of discharge phone calls that need to be done on 6

6. Central, I am inclined to recommend that at least one nurse a day be scheduled between
the hours of 8am and 5pm for the sole purpose of helping with admissions, discharges,
teaching, and discharge phone calls. At the very least this nurse could help by providing a
60-90 minute discharge teaching class for first time mothers and make discharge phone
calls. It would be beneficial if that nurse could do a second 60-90 minute class for
Spanish-speaking moms, or cover the patients of a Spanish-speaking nurse while she
teaches the class. These two indicators alone should improve patient and nurse
satisfaction. If the ADT nurse finishes these two tasks and can help admit and/or
discharge some patients, that would be a bonus, and it would also increase patient and
nurse satisfaction. I believe that starting on a small scale with just one nurse in this role
would have a large impact, and the hospital could then consider adding another ADT
nurse. If the ADT nurse is someone who is reluctantly considering retiring because
bedside nursing is becoming too physically demanding, this position could help with
retention of at least one valuable, experienced nurse.

7. Bibliography
Dudas, V., Bookwalter, T., Kerr, K. & Pantilat, S. (2002). The impact of
followup telephone calls to patients after hospitalization. Disease a Month,
48(4), 239-248.
Fact Sheet: General Facts on Women and Job Based Health. (2013, December 1).
Retrieved July 6, 2014, from http://www.dol.gov/ebsa/newsroom/fshlth5.html
Giangiulio, M., Aurilio, L., Baker, P., Brienza, B., Moss, E., & Twinem, N. (2008).
Initiation and Evaluation of an Admission, Discharge, Transfer (ADT) Nursing
Program in a Pediatric Setting. Issues in Comprehensive Pediatric Nursing, 31,
61-70. doi: 10.1080/01460860802023117
Kirkbride, G., Floyd, V., Tate, C., & Wendler, M. (2012). Weathering the storm: Nurses’
satisfaction with a mobile admission nurse service. Journal of Nursing
Management, 20, 344-353. doi: 10.1111/j.1365-2834.2011.01273.x
Lane, B., Jackson, J., Odom, S., Cannella, K., & Hinshaw, L. (2009). Nurse Satisfaction
and Creation of an Admission, Discharge, and Teaching Nurse Position. Journal
of Nursing Care Quality, 24(2), 148-152.
Needleman, J., Buerhaus, P., Pankratz, V., Leibson, C., Stevens, S., & Harris, M. (2011).
Nurse Staffing and Inpatient Hospital Mortality. New England Journal of
Medicine, 364, 1037-1045. doi: 10.1056/NEJMsa1001025
Spiva, L., & Johnson, D. (2012). Improving Nursing Satisfaction and Quality Through
the Creation of an Admission and Discharge Nurse Team. Journal of Nursing
Care Quality, 27(1), 89-93. doi: 10.1097/NCQ.0b013e318227d645