Date of Award

Spring 5-2023

Document Type

DNP Project

Project Team Faculty Member

Amy Hamilton

Project Team Faculty Member

Frank Lyerla


patient hand-off, transition of care, discharge communication, electronic health record, post-discharge adverse events, continuity of patient care


Conducting hand-off communication among healthcare providers can impact patient outcomes. Lack of communication between healthcare entities at the time of care transition can produce patient harm and lead to adverse events such as medication errors, hospital readmission, and unnecessary emergency department visits. The project goal was to evaluate the impact of communication between acute care and primary practice nurses using a standardized, electronic communication tool within the EHR upon patient discharge from a community-hospital based setting. During implementation, forty-two patients were included in the project based on primary practice follow-up location. Of the 42 eligible patients, the acute care nurses successfully transmitted electronic hand-off communication on 36 patients to the appropriate primary care practices. After the adoption of the electronic hand-off communication tool, only one patient (2%) was readmitted within 30 days of hospital discharge. In addition, only one of the 42 patients visited the emergency department during the project implementation period. Nursing engagement supporting the use of an electronic hand-off communication tool was apparent during implementation based on participating feedback from nurses recommending continued use of the standardized, electronic communication tool. By using an electronic communication tool, care transition was enhanced at the time of hospital discharge. Adverse outcomes, such as hospital readmission, can be prevented through hand-off communication between the acute care and primary practice settings at the time of patient discharge.

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Nursing Commons



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