The Report on Readmission Rates of Congestive Heart Failure

Evidence-based research is used to implement decisions based on research, allowing the nurse to improve quality patient outcomes. For this evidence research proposal, the author will discuss comprehensive discharge planning and continuity of care post discharge of congestive heart failure (CHF) patients in decreasing hospital readmissions in thirty days after discharge. This paper will include a single study research approach of ten research-based articles related to the topic of CHF and readmission rates. A quantitative approach will be used to identify the data collection and sampling used with the targeted population and to implement how the research will be gathered. In conclusion, this project will also look at the proposed practice of the change model (PDSA) to determine how it is suitable in regards to this research project. This question will be measured utilizing ten evidence-based research articles to support the applications of effective comprehensive discharge plan and continuity of care for heart failure patients.

In the article titled, “Nurse-led early discharge planning for chronic disease reduces hospital readmission rates and all-cause mortality”, (Fox, 2016) this study focuses on identifying adequacy of nurse-led discharge planning programs, for CHF patients, that begin when the patient is admitted to an acute setting. This research article measured nurse-led discharge planning programs to standards of care that were not initiated within forty eight hours of admission, while evaluating the outcomes. This article is a grounded theory and quantitative study, involving Ten Randomized Controlled Trials (RCT), incorporated 3,438 participants who were admitted with CHF, of a psychiatric disorder,and hip fracture. This nurse-led discharge planning intervention, correlated to hospital standards of care, was initiated within forty eight hours upon admission. The conclusion of the study was that early discharge planning programs that are nurse-led are effective in reducing hospital readmissions by 28%. In addition, patients duration of hospital stay was decreased by a little over 2 days, death rates were decreased by 30%. In comparison to general care, hospital costs were reduced when compared non-nurse led discharge planning programs that were not put in place upon admission. The sample size, variety of population, and low risk of bias all strengths of this article. Limitations include differences in healthcare institutions and lack of monetary freedom.

In the article titled, “The Role of the Nurse Navigator in the Management of the Heart Failure Patient” (Monza, Harris, & Shaw, 2015), this study took into consideration the meaning of the role of the nurse driven and its interrelationship to reduce CHF readmission. The research was a descriptive, qualitative study and utilized a grounded theory. The research took place in three different facilities in a year time span. The intervention which is known as the Heart Success Transition Clinic (HSTC). This goal was to assist with the transition between the acute care stay and discharged to a rehabilitation setting or discharged to home from acute care,with the end goal of reduce CHF readmission, within 30 days of discharge.The outcome of the study indicated a decrease in the amount of hospital CHF readmissions within 30 days of discharge,involuntarily raising patient satisfaction. Strengths include, increase in resources for patients due to more nurse”navigator” roles created and multiple hospitals where the study took place. There is a limitation due to the exact number of readmissions is unknown.

In the article titled, “A bundled intervention including early consultation with a cardiologist in the emergency department to reduce re-hospitalizations and healthcare cost for high-risk urban patients with acute decompensated heart failure,” (Tabit, Coplan, Spencer, Sanghani, & Liao, 2017), this study was conducted in order to assess if multidisciplinary interventions has an impact on decreasing readmission for patients with CHF if started in the emergency department, also how it will affect healthcare costs for the same patient population. The study was of qualitative research and randomized control trial. The patients were giving a cardiologist consultation, nursing education, dietitian, and pharmacy follow-up as part of the intervention. The control group of 392 participants received general care of the hospital for CHF admission. Participants returning to the hospital received the intervention. Data collection were random sampling and the CHF patients in the research group were given the” Minnesota Living with Heart Failure Questionnaire (MLHFQ)”. The results indicated that the group who received the intervention was associated with decreased readmission to acute care. This study was random making it unbiased.. A limitation of the study was chronic chf patients were not captured.

The article titled, “Predicting readmission of heart failure patients using automated follow-up calls” (Inouye, Bouras., Shouldis, Johnstone,Silverzweig, Z,& Kosuri,2015). Purpose was to investigate if automatic calls made to patients could determine those who are at increased risk of readmissions to the hospital within 30 days of discharge, and the data was collected by quantitative research. The study used an automatic follow-up call to patients following discharge home. The patients inputted responses using a telephone. The patients received two automatic calls forty-eight hours after discharge. “Pearson’s chi-square test” is utilized in order to assess if readmission risk was due to patients participation in the follow up call.The results showed that out of 1095 CHF patients 837 patients responded to the first call while 515 patients interacted with both calls, 244 patients were readmitted within 30 days post-discharge. Sample size was over 800 which was a strength of the study. A limitation to the study showed to be bias, the participants had to be English-speaking and have the means to use a telephone.

In the article titled, “Knowledge of Heart Failure: Implications for Decreasing 30-Day Re-Admission Rates” (Sterne, et al, 2014) the researcher was evaluating nurses' knowledge of CHF and following through with discharge education. This study evaluated the effect of increasing the knowledge of the bedside nurse of CHF. The bedside nurse was provided in-services in regards to CHF. The studier access if the education provided by the bedside nurse to the patient would have an effect on readmission of patients with CHF. This was a quantitative study which utilized the grounded theory method. 300 nurses were involved in the study who worked directly with heart failure patients. Nurses were given a pretest as well as a post-test to assess their knowledge of CHF and their delivery of discharge education to patients. Thirty minute PowerPoint was shown about “The Joint Commission’s Heart Failure Guidelines and the American Heart Association”. “Get with the Guidelines” campaign, was shown in between test. Providing key points of CHF management. The results of the post –test showed that nurses’ knowledge of CHF had improved from the pre-test, nurses were able to provide comprehensive discharge education. Nurses answered approximately 80% of the questions correctly. In conclusion, the study had solid datat that such nurses educational programs are beneficial providing a positive impact on patient outcomes and reducing readmission. Data including three consecutive months, readmissions were reduced by providing more education to the nurses. The strengths of this study is the positive impact of continuing education for staff nurses and the use of evidence based research. The sample size was small, limiting the research.

The article titled, “Trends in 30-Day Readmission Rates for Patients Hospitalized With Heart Failure (Bergethon, Ju, DeVore, Hardy, Fonarow, Yancy, Heidenreich, Bhatt, Peterson, and Hernandez 2017). The purpose of the study was to analyze research from the (American Heart Association's) “Get with The Guidelines Heart Failure (GWTG-HF) registry from 2009 to 2012” (Bergethon et al.,2017). The studier utilized “multivariable linear regression model” to collect data for this study. The results show that out of 21,264 patients with the diagnosis of CHF from seventy sites within the United States, all had a decline in readmission rates from twenty percent in 2009 to nineteen percent in 2012. The study results also show that hospitals who referred their patients to disease management programs had lower readmission rates and that teaching hospitals had higher readmissions over nonteaching hospitals. A strength of the study was that the data collected was from hospitals nationwide so this could potentially help to differentiate between hospital management systems and its effects on hospital readmissions. The study was limited in only including patients enrolled in Medicare, therefore no compraisions on the effects of private versus public insurance (Bergethon et al., 2017).

The article titled, “ Readmissions, Observation, and the Hospital Readmissions Reduction Program '' (Zuckerman,Sheingold, Orav,Ruhter, and Epstein,2016). This study concentrated on the hospital readmissions reduction program ( HRRP) of the ones associated with the” Affordable Care Act” (ACA) that penalized financially for higher readmission rates. The participants fell in the medicare members age 65 year or older diagnosed with pneumonia (PNA acute myocardial infarction (AMI), or CHF, The studier used The research took place at 3,387 and showed readmission rates declined from 21.5% to 17.8%, data showed readmission declined significantly for hospitals under the ACA in order to avoid financial penalties healthcare facilities, Data was collected between the years of 2007 – 2015. In this study non experimental design and was a qualitative study was utilized. Research data showed when implementation of the HRRP readmissions were decreased for CHF within 30 days of discharge. Strength was the large sample size the prolonged time frame of the study. The nonexperimental design of this study placed limitations on the ability to draw an affiliate link between the HRRP and the outcomes of interest.

The article titled, “ Impact of a pharmacy team—lead intervention program on the readmission rate of elderly patients with heart failure” (Moye, Chu, Pounds, & Thurston, 2018) purpose of this study was to determine if pharmacy intervention would have an impact on post-discharge and decrease 30-day CHF readmissions. The patient would have their medication reconciliation with the pharmacist and one on one counseling. The patients must have a primary diagnosis of CHF. This was a qualitative study with a retrospective design. There were two groups, research group and a control group. The research group was provided the intervention while the control group was from chart review of historical patients with the similar data. This study showed a lower readmission rate with the patients who received the one on one pharmacy intervention compared to the control group. The strength of the study was that it was inexpensive, and the time frame was 15 months, also it was not bias due to it being random. The weakness of the study was that the control group data was not mirrored. The patients in this control group were older patients.

The article titled. “Relationship between early physician follow-up and 30-day readmission after acute myocardial infarction and heart failure”(Tung, G. Chang, H. Chang, and Yu, 2017). The purpose of this research study,to find the link between early physician follow-up and the effects on readmission rates of CHF and heart attack patients; however, for the purpose of this project we will only discuss findings for the CHF population group. Data was collected using an observation and retrospective approach. The study involved a national health insurance research database to analyze data on 13,577 CHF patients discharged in 2010. The results of the study showed with early provider intervention there was a lower readmission rates compared to no early provider intervention. A strength of the study was the information is readily available to the public through a national database. Therefore, the study didn’t need to have patient consent or inclusion criteria. A limitation to this study patients not being randomly assign which could result in being bias.

The article titled, “A clinical pathway for heart failure reduces admissions from the ED without increasing congestion in the ED”, (Spiegel, Wasserman, Neumann, Coplan, Spencer, Adelman, Sanghani, & Tabit, 2017) purpose was to see if the avenue for CHF patients, that included multiple interventions to start in the emergency department would have an effect on CHF readmissions without increasing emergency room congestion. The approach was quantitative st approach using randomized control trial. The patients taking part in this research received cardiology consultation, follow up appointment support, pharmacy consults, dietary, physical therapy, as well as nursing support. Standard of care giving to the control group received. The results showed that the research participants were 13.1% less likely to be readmitted to acute care. The strength of the study was that it was a random sample. The limitation of the study was there was some limitation with provider times for discharge follow-up.

Research Approach and Design

A quantitative approach would be used to answer this PICOT question as this approach focuses on scientific methods that provides numerical data on the evidence-based research. It is used to quantify beliefs, assessments, attitudes, and other defined variables. Quantitative research uses data to generate facts and arrangement in research. A critical advantage of this is that the examiner is able to ensure that the control group is useful opposite the intervention group. A disadvantage is that one could alter the results without attempting to do so since it is not necessarily random and involves combining interventions. “Biased can be described as control over study design, participants, what exactly is being measured which could limit the research itself” (Eddy, 2016). This approach fits into my evidence-based approach as I am attempting to gather numerical data of heart failure patients who receive effective comprehensive discharge plan and continuity of care and how it affects the outcomes of hospital readmission rates.Since I am also attempting to look for an outcome between two separate population groups of patients those who are not readmitted within 30 days after discharge versus those who are admitted within 30-days of discharge. The quasi-experimental design approach will be useful in this authors research. The timing and costs of research can make it difficult for researchers to gather information on an entire population as a result sampling techniques are used to assist in the selection process (Kandola, Banner, O’Keefe-McCarthy, & Jassal, 2014)

Sampling

I will be using a probability sampling approach as this is a random selection of items from variables, where each item has an equal and individual chance of joining in the sample. Simple random sampling will be used as it is statistically approach to random probability sampling. In CHF evidence-based approach the participants would be selected randomly and assigned to control groups and experimental groups respectively. The control group make up with be CHF patients who are admitted to the floor and receive standard of care. “One advantage to probability or random sampling is that bias is eliminated. One disadvantage of probability or random sampling is that the sample set of the larger population may not be inclusive enough” (Emerson, 2015). I will use a sample size of 50 to 100 patients will be used for this project with an inclusion criterion that consists of a targeted population for this evidence-based approach. Which will be patients with a diagnosis of CHF ages 65 years and older. Exclusion criteria will include participants who are younger than 65 years old, who had a hospital readmit within thirty days from the prior discharge, those who are unable to participate due to other comorbidities. Those that are mentaly incapable, non-compliance, or those who refuse. Research participants will be protected by anonymity and safeguarding patient names. All information will be kept in a computer system that is password protected. The importance of not sharing data collected with third parties will be emphasized along with participants information such as addresses and other personal identifiable information will not be used.

Change Model

“The plan-do-study-act change model is a leadership and management model used to enhance change within evidence-based research”( Donnelly&Kirk 2015). “This model is often used in assisting teams to improve the quality of patient care” (Donnelly & Kirk, 2015). For this Evidence Based Project, the Evaluation Framework and Process Model will be used to implement change. The Evaluation Framework was chosen for this plan because “the Evaluation Framework allows different aspects of implementation that could be evaluated and used to determine the success of the implemented intervention” (Nilsen, 2015). The Evaluation Framework would assess if comprehensive discharge planning begins on admission and continuity of care will decrease readmission among patients with CHF.”The Process Model is used to describe the process of converting research and data into practice, and provides practical guidance for successful implementation in practice” (Nilsen, 2015). The Process Model was selected for this project because following the evaluation of the data and determining the success of the intervention, the Process Model supports the researcher in creating a new standard of care. One barrier to implement proposed practice change of early discharge resources may be lack of finance. Resources of educational pamphlets are needed to provide the standardized education so that each provider is delivering the same material. Having the financial data available, educating the hospital on their financial obligation, showing data of what the facility would save by reducing CHF readmissions and how much to implement new standard of care will cost the hospital would overcome a huge barrier up front. The challenge this author would face is showing the financial officer that the benefit of providing these resources outweighs the cost. An environment of evidence based practice can cultivate continuing education at the floor level. Enlisting the assistance of coworkers, committees, patients, and other members of the interdisciplinary team. Joining professional organizations like the American Heart Association and using scholarly references will help me advance the evidence into practice allowing me to proved the best patient outcome in my future setting.