IRCT20180408039238N1 IRCT 2018-09-10 Faculty of nursing and midwifery of Tehran university of medical sciences The impact of transitional care upon the rate of readmission in patients after Coronary Artery Bypass Graft The impact of transitional care upon the rate of readmission in patients after Coronary Artery Bypass Graft 2018-05-22 anticipated 80 Complete https://irct.ir/trial/30552 interventional Randomization: Randomized, Blinding: Not blinded, Placebo: Not used, Assignment: Parallel, Purpose: Prevention, Randomization description: Random blocking. N/A Coronary Artery Bypass Graft Surgery. Intervention 1: Intervention group: In intervention group, patient or his/her home caregiver is trained by researcher about how to keep connection with researcher from home and help tele-nursing. Instructions consists of how to measure body temperature, pulse rate, respiratory rate, blood pressure, efficient using of incentive spirometry, stair workout, walking, appropriate position (sleeping, sitting and during activities), using medications, assessing and caring sternal or limb incision, measuring weight, warning signs and what to do if those occur, wearing sternal support, suitable diet precautions when taking a bath, praying and during travel. Patient/ home caregiver sends to researcher ,by internet messaging, a report from patient's condition(using the report form designed by researcher) each night in first week after discharge. It is said to patient that she/he can contact researcher by phone call or voice message in case of a new problem or needing to ask question. In case of not sending reports regularly, researcher reminds patient/caregiver by phone call. Researcher contacts patient/home caregiver in case of suspicious conditions and gives some advice or in serious cases recommends patient to return to the initial hospital or first hospital near his/her home. . Researcher does two sessions of home visit ;one in first week after discharge and second session two weeks after first session. In each session, general assessment of patient's state is done, researcher observes implementing instructions by patient and recommends referral to surgeon or other specialists if needed. Patient is recommended to return initial hospital or other hospital in case of occurrence of warning signs between home visit sessions and every other time needed. Intervention 2: Control group: This group will receive rutine care in hospital and after discharge follow ups. Ultimately, researcher will measure 30 day readmission rate in this group and will compare two groups. No - There is not a plan to make this available Justification or reason for not sharing IPD is we have not decided about this topic yet.