SHM Converge Scientific Abstract ePoster Gallery-Advancing Heart Failure Transitions: Structured Post-Discharge Strategies to Prevent Early Readmissions

Pdf Summary

This quality improvement project aimed to reduce 7-day readmissions for patients discharged with congestive heart failure (CHF) by improving post-discharge follow-up. The initiative was implemented on two high-volume inpatient units and included structured telephone support, targeted nurse education, and a standardized discharge/call protocol. Six nurses participated, and only adult patients discharged home were included; patients transferred elsewhere, enrolled in hospice, or unreachable were excluded. Follow-up calls were made within a 72-hour post-discharge window.<br /><br />The background highlighted that heart failure is a leading cause of hospitalization and early readmission, with many rehospitalizations occurring within the first week after discharge. Contributing factors identified locally included limited patient understanding, inconsistent post-discharge practices, and delayed escalation of care.<br /><br />Results showed meaningful improvement after implementation. Seven-day readmissions decreased from 6.28 to 4.21, which was statistically significant (P = 0.010). There was also an inverse relationship between timely follow-up call adherence and 7-day readmissions (p = .001), indicating that better compliance with follow-up calls was associated with fewer readmissions. Nursing knowledge of heart failure management also improved substantially, with mean test scores rising from 62.82 to 89.30 after education.<br /><br />Overall, the project demonstrated that structured post-discharge telephone calls combined with nurse education can significantly improve transitional care and reduce early heart failure readmissions. The authors noted some variation between units in protocol adherence and suggested that similar interventions be tested on other units to further assess effectiveness.

Asset Subtitle

Nikhil Seth

Meta Tag

Author List Allison Heinen, Gracy OKoko-Adabla, Nikhil Seth

Category Research

Concept Heart Failure

Concept Readmission

Concept Transitional Care

Concept Telephone Support

Concept Discharge Management

Distinguished Non-Finalist

Presenter Organization Baylor College of Medicine

Presenting Author Nikhil Seth

Track Transitions of Care

Keywords

congestive heart failure

7-day readmissions

post-discharge follow-up

telephone support

nurse education

discharge protocol

transitional care

heart failure management

readmission reduction

quality improvement

Heart Failure

Readmission

Transitional Care

Telephone Support

Discharge Management