Critical Care Nursing Commons^™

Enhancing Heart Failure Transitional Care To Reduce 30-Day Readmission Rate, Thuy Nhu Uyen Tran

Doctor of Nursing Practice Final Project Abstract

Purpose: The purpose of this quality improvement (QI) project is to reduce 30-day readmissions for adult patients with heart failure (HF) by implementing a standardized HF pathway beginning in the intensive care unit (ICU) and continuing through discharge.

Background: The project was implemented within a large healthcare organization in Northwest Houston, Texas.

Methodology: This project utilized a pre- and post-implementation design guided by the Plan-Do-Study-Act (PDSA) model. Eligible adult patients (≥18 years) with a primary or secondary HF diagnosis were identified during March 2026. The My Pathway to Wellness HF education pathway was initiated at the time of ICU downgrade …

Implementation Of A Cardiomems Screening Tool To Increase Provider Awareness And Referrals In Eligible Patients, Monica Rios

DNP Projects

Background: Heart failure affects over 6 million Americans and causes more than one million hospitalizations annually. CardioMEMS, a remote pulmonary artery pressure monitoring device, effectively reduces hospitalizations, yet its use remains limited due to provider and system barriers. The purpose was to increase CardioMEMS referrals for eligible heart failure patients through targeted provider education and a standardized screening tool.

Local Problem: Kentucky experiences higher heart failure hospitalization rates than the national average, contributing to prolonged hospital stays and rising healthcare costs.

Methods: A pre—post quasi-experimental study was conducted at an academic medical center. Baseline chart review of 47 patients evaluated …

Evidence-Based Discharge Bundle To Reduce Heart Failure Readmissions, Chelsea Zepeda

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: Heart failure (HF) affects over 6.7 million adults in the United States, resulting in frequent hospitalizations and readmissions, increased mortality, and billions of dollars spent annually on healthcare costs. Reducing readmission rates is a priority for the healthcare industry.

Objective: This evidence-based practice project aimed to reduce HF readmission rates through a bundled approach to address socioeconomic factors that place patients at higher risk for readmission, provide patient-centered education for HF management at home, and provide follow-up phone calls after discharge to assess patient symptoms.

Methods: English-speaking patients, aged 65 or older, with any active diagnosis of HF were …

Optimizing Discharge Education For Hf Patients, Connie-Rose Pangan

Nursing | Student Research Posters

Heart failure is a chronic condition in which the heart cannot adequately provide blood and oxygen to tissues in the body. Heart failure patients account for the highest 30-day readmission rate in Medical-Surgical conditions (Nair et al., 2020). It is the leading cause of hospitalization in adults over 65 years old in the US. Constant readmission is costly, and therefore additional interventions must be done to prevent it. Due to the severity of heart failure, these patients require a copious amount of information at discharge to understand the pathophysiology of their disease, their medication regimen, and important lifestyle changes needed …

Teach-Back Education In Heart Failure Patients Benchmark Study, Bethany N. Johnson

MSN Capstone Projects

Heart failure exasperation is one of the most common causes of hospital readmission in the United States (Breathett et al., 2018). It is estimated that greater than half of all heart failure patients will be readmitted to the hospital within six months of discharge (Caluya, 2021). Additionally, one in four individuals with heart failure are readmitted within thirty days of discharge (Rahmani et al., 2020). This data shows a large area of improvement for hospitals in order to improve patient outcomes. Due to the lack of standardized discharge teaching, heart failure patients are often admitted to the hospital for the …

Exploring The Influence Of Contextual Factors And The Caregiving Process On Burden, Quality Of Life, And Outcomes Of Heart Failure (Hf) Dyads After A Hospital Discharge Guided By The Individual And Family Self-Management Theory (Ifsmt): A Mixed Method Study, Tamara Bernard

Theses & Dissertations

ABSTRACT The purpose of this study is to explore the influence of contextual factors and caregiving process characteristics on proximal outcomes of the patient and caregiver after discharge from the hospital. The long-term goal of this research is to reduce caregiver burden and improve patient outcomes. Heart failure (HF) is an increasingly common chronic illness with unique caregiving needs and a high rate of hospital readmissions. Caregiver burden has been researched extensively in other areas of medicine such as oncology and dementia and has been reported for stable chronic HF patients in an outpatient setting. However, there is little research …

Adults With Preexisting Diagnosis Of Heart Failure In The Environment Of Coronavirus Disease 2019, Ronald Phillips

Dissertations

Background: Heart disease continues to be the leading cause of death among adults in the United States and other industrialized countries. Heart failure (HF) is a form of heart disease and has become an epidemic with complications and medical care costs increasing at an alarming rate. HF affects more than 5.7 million adults in the United States with an incidence between 550,000 to 670,000 annually, primarily affecting females, African Americans, and adults aged 55 years and older. HF is also associated with a high rate of mortality, estimated to increase, with a risk rate of 13%, 32%, and 64% among …

Education Regarding Advance Directives Improves The End-Of-Life Choices Documentation In Heart Failure Patients, Phebe Hagins Wright

Doctor of Nursing Practice Projects

Background: Heart failure affects the lives of more than 6 million people in the United States and outpatient heart failure clinics offer an opportunity to educate patients while providing evidence-based care. A needs analysis revealed that many heart failure patients do not have an advance directive (AD) on file.

Purpose: The DNP project aims to implement an educational program that provides the tools and knowledge to heart failure patients to assist patients in determining their end-of-life care goals and allow them to document these goals in the Five Wishes document.

Methods: This quality improvement project consisted of a didactic educational …

Keep The Beat With Heart Failure Education: A Quality Improvement Project, Brenda L. Peterson

Master's Projects and Capstones

Abstract

Problem: Heart failure (HF), also known as congestive heart failure (CHF), is the number one diagnosis-related group (DRG) for people 65 years of age and older in the United States. This disease group is complicated and debilitating, requiring frequent hospitalizations with high mortality rates. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has identified CHF as an area for improvement in hospitals.

Context: This was a quality improvement project for an integrated medical center in the Central Valley, California with over 19,000 HF patients. In 2018, for patients 65 years and older, HF is the third-most admitted DRG …

Assessment Of Nursing Knowledge Before And After Implementation Of Educational Intervention On Heart Failure, Sarah Scott

Dissertations

Purpose: The purpose of this study was to assess the knowledge of nursing staff on a cardiology unit before and after the implementation of heart failure specific education. Methods: Forty staff nurses on a cardiology unit at a single institution were given The Nurses Knowledge of Heart Failure Education Principles Survey (NKHFEP), a validated tool to assess nursing knowledge of heart failure. A series of four educational sessions were given to the same forty nurses. They were then given the NKHFEP survey a second time to assess change in knowledge post educational intervention. Results: The mean of Pre-education (M = …

The Effect Of An American Heart Association Telephone Follow-Up Intervention On Knowledge And Self-Efficacy In Rural Heart Failure Patients, Haley Fuller

DNP Projects

Background: An increased national and local prevalence of heart failure fostered a review of the evidence to identify best practice interventions focusing on improving self-care and knowledge. Heart failure remains a leading cause of 30-day readmission in the United States and in Madisonville, Kentucky, the site of study. A review of the literature emphasized improving transitions from hospital to home with a multi-dimensional approach. Self-care and knowledge were identified as major determinants to adequately prepare a patient to manage this chronic disease. A pre- and post quasi experimental study was performed at a rural hospital in Kentucky. Objective: The goal …

An Exploratory Study Of The Utilization Of Evidence-Based Pharmacological Treatment On Heart Failure Patients In Mississippi And Its Impact On Readmission, Keri A. Barron

Dissertations

The purpose of this study was to explore the relationship of adherence to evidence-based guidelines for pharmacologic management by select Mississippi hospitals and their hospital readmission rates. This was an exploratory study with a retrospective design. This design offered insight into the relationship between readmissions of heart failure patients and adherence to the national guidelines for the pharmacologic treatment of heart failure. The study took place in a hospital in the southeastern section of the United States. Data were collected from a database of patients with heart failure seen between January 2011 and June 2014.

The unit of analysis for …

Effect Of An Emergency Nurse Heart Failure Educational Intervention, Lori Hudgens

Doctoral Projects

Background: Research indicates many nurses lack the appropriate heart failure (HF) education necessary to assist with readmission reduction efforts. Employer approved nurse HF education has resulted in improved nurse HF knowledge, and, reduced readmissions.

Problem: ED nurses require a competent knowledge of heart failure to effectively educate heart failure patients upon admission to the ED. No research has been conducted with ED nurse specific populations to assess ED nurse knowledge of heart failure, and, to determine if heart failure educational interventions increase ED nurse' HF knowledge.

Aims: To evaluate the effectiveness of an ED nurse b.eart failure educational intervention in …

The Impact Of Self-Care Education On Heart Failure Patients With A High Risk For Readmission, Neil Williams Ii

Nursing Theses and Capstone Projects

The purpose of this Capstone Project study was to answer the question: Does self-care education improve knowledge and decrease 30 day readmission rates in a class of heart failure patients that are at high risk for exacerbation? The study used a randomized control design with a pre-test/post-test. A convenience sample of 50 African Americans diagnosed with heart failure were entered; control group (n=25) and experimental group (n=25). Both groups received the Heart failure Pre/Post Test developed by the researcher during the initial interview and four weeks post discharge. The experimental group received a phone call weekly over the four weeks …

Comparing Must And The Nri Tools In The Identification Of Malnutrition In Heart Failure Patients, Cassondra D. Degener

DNP Projects

The purpose of this project was to test the performance of albumin, NRI and MUST screening tools in comparison to the standardized measure of prealbumin among HF patients admitted to the University of Kentucky Chandler Medical Center. Inclusion criteria included all HF patients with the 428 diagnostic code, admitted from January 1, - December 31, 2013, ages 18 and older, with all laboratory values available specified in the data collection tool (Appendix A). A retrospective electronic medical record (EMR) review was performed for 100 patients who met the inclusion criteria. All data were collected through the University of Kentucky’s secure …

The Significance Of Timing Of Patient Daily Weights And The Barriers, Ann Pan

Master's Projects and Capstones

Background. Current unit practice is that patient daily weights are obtained in the afternoon or evenings. However, patient weights in the afternoon and evenings are not accurate dry weights. According to evidenced based research, to obtain an accurate patient daily weight, patients should be weighed every morning, after their first void and before they eat breakfast.

Purpose. The focus of the study was to compare the current practices of obtaining daily weights in the afternoon and evenings, compared to the evidenced based practice recommended in the literature.

Method. Through interviews and surveys with staff, the barriers to obtaining patient weights …

Pilot Study: Avoiding Readmissions Of Heart Failure Patients Across Transitions Of Care, Analiza Baldonado

Doctoral Projects

Background: A major problem facing the U.S. healthcare system is avoidable hospital readmissions. Patients with Heart Failure (HF) face variety of barriers to health care and are at higher risk for readmissions. To address this problem, evidence-based interventions focused on safe transition from hospital to home are needed.

Methods: A quality improvement pilot project was implemented to evaluate the feasibility of evidence based interventions in preventing avoidable readmissions. The project setting was in a 900 bed health care system. The descriptive statistical methods were means and frequencies. The Transition Coordinator (TC) enrolled a convenience sample of 30 participants. The evidence …

Early Home Visits By A Registered Nurse Care Manager With Heart Failure Patients, Dana Davis Blake

Nursing Theses and Capstone Projects

Strategies focused on 30 days in the life of a patient with heart failure will have limited impact on the burden that heart failure will have nationally or individually. The broader landscape of readmission risk underscores the need for a more comprehensive approach to heart failure management. Care management with a registered nurse demonstrated efficiently coordinate care. Home visits address the peaks of risk in the post-discharge transition and palliative phase while providing longitudinal support. The purpose of this study is to substantiate that early home visits and telephone followup with a registered nurse after discharge from the hospital will …