Background:
Patients hospitalized with congestive heart failure are more likely to be readmitted than any other group. We found our hospital's 30‐day readmission rate for heart failure patients to be 22% for any cause and 8.5% for the same diagnosis. Heart failure was the top readmission diagnosis, and the readmission rate had been steadily increasing. Other organizations have employed care transition models, posthospitalization teaching, and self‐management strategies for reducing heart failure readmissions. Besides medical management, it is unclear what specific interventions during a hospitalization may contribute most to decreasing readmission rates for heart failure patients.
Methods:
Using the Transforming Care at the Bedside tool, we flowcharted our discharge process and noted gaps in preparing our heart failure patients for discharge. To identify primary contributors to readmission in our patient population, we used the Six Sigma Voice of the Customer process to survey patients readmitted with heart failure. Discoveries included 51% reporting not receiving educational materials during their previous hospitalization, 75% not weighing themselves daily, and 39% not understanding the need to track their weight. Furthermore, 31% of those surveyed had not followed up with an outpatient physician prior to their readmission. After employing a collaborative process to identify heart failure patients, we created a multi‐disciplinary protocol to provide focused education and care coordination during their hospitalization. We developed a checklist of 10 items to be addressed with each patient, and it required interventions from nurses, physicians, nutritionists, unit managers, unit clerks, and performance improvement personnel. Patients received calendars with educational messages. They learned the importance of weighing themselves and when to call their provider. If they did not have scales at home, they were given digital scales. Follow‐up appointments were made for the patients prior to discharge. The protocol was piloted for 3 months in the cardiac nursing unit, where the majority of our hospital's heart failure patients receive care. Costs were minimal and limited to printing calendars and purchasing scales. We used existing resources otherwise. Limitations included our using a convenience sample of patients for the survey and not comparing readmission rates for patients with a secondary diagnosis of heart failure.
Results:
The 30‐day all‐cause readmission rate for the pilot group was 10.7%, significantly less than our previous rate (27.6% for the same nursing unit and 22.4% for the entire hospital).
Conclusions:
Even though hospitals are not directly involved in primary care after discharge, a well‐managed protocol of multidisciplinary efforts during a hospitalization directed toward identifying and addressing postdischarge needs can reduce 30‐day readmissions for heart failure patients.
Disclosures:
D. Boyte ‐ none; L. Verma ‐ none; M. S. Wightman ‐ none