Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project

Heart failure (HF) is a highly prevalent, costly public health concern in the United States¹  that continues to be the leading cause of hospitalization and rehospitalization within 30 days of discharge.²  Follow-up visits within 7 days of discharge are an effective care-transition intervention for reducing HF readmission.³  The American Heart Association guideline for the management of HF recommends a follow-up visit 7 days after discharge from the hospital as 1 of the interventions in preventing HF readmissions; however, hospital adherence to this recommendation varies significantly across the United States.⁴ 

The HF readmission rate in our unit was similar to the national rate of 21.6%.⁵  At our hospital, administrators are supportive of nurses improving care processes that may affect unplanned readmissions for this patient population. A process map of care of the patient with HF at discharge and follow-up was made to identify gaps in care....