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

Abstract

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.4The 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. The registered nurse (RN) was responsible for checking that the appointment was made and informing the patient and family during discharge teaching. Often, the discharge paperwork exceeded 15 pages, the RN would forget to highlight the appointment, and it would get lost among all the other instructions. According to internal quality data collected during 3 months (from July 1 through September 30, 2016), of the 63 patients discharged to their home, 22 (35%) did not have a scheduled 7-day follow-up appointment before discharge and only 25 (40%) of the patients with an appointment kept it. It also was unclear what providers were including in the 7-day follow-up visits.To address this gap in care, we used the Institute for Healthcare Improvement’s Model for Improvement as the framework to guide the planning, implementation, and evaluation phases of an evidence-based practice quality improvement project. The model consists of 6 steps: setting aims, establishing measures, selecting changes, testing changes, implementing changes, and spreading changes.6 The project manager was a student in a Doctor of Nursing Practice program who was required to complete an evidence-based practice quality improvement project for this degree. The project manager was an advanced practice nurse with experience in caring for complex HF patients. The academic partner was a nurse with strong cardiovascular background and experience in guiding practice-change projects. The practice mentor was an advanced practice nurse who treats patients with HF in the practice setting facility and leads the hospital HF transformation program. The team also included nurses who were experts in data collection and tracking of patient outcomes.Our aim was to improve the process for scheduling follow-up visits for patients with HF at 7 days after discharge from the hospital, to track the number of patients who kept their 7-day appointment, and to compare 30-day readmission rates 3 months before and after the process improvement change. A secondary aim was to assess the elements local health care providers included in 7-day follow-up visits.Our unit is a 20-bed acute care telemetry unit in a 397-bed, academic teaching, regional center for cardiac care located in southwestern Connecticut. All patients who were discharged to home from our telemetry unit with a primary diagnosis of HF or an International Classification of Disease, 10th revision (ICD-10), code for HF.Data on the scheduling of 7-day follow-up appointments were obtained from the HF Patient Management Tool from the American Heart Association’s Get with the Guidelines HF Registry7 and the reports created by Quintiles (IQVIA) for all patients discharged with a primary diagnosis of HF according to ICD-10 codes.Data on the 7-day follow-up appointments were obtained monthly from a contact person at each of the 2 major cardiology groups affiliated with the practice setting. Patients’ demographic characteristics and data on 30-day readmission rates were obtained from reports generated by Premier (Premier Inc), the database used by our hospital’s Quality Management Department to track and monitor 30-day readmission rates for all patients discharged with a primary diagnosis of HF as designated by ICD-10 codes.We created a questionnaire to measure provider adherence to best practices at 7-day follow-up visits after hospital discharge for patients with a primary diagnosis of HF. Providers were asked to respond yes or no to the questions listed in Table 1.The implementation of an appointment card was the intervention used for change. The fourth step of the Model for Improvement is testing the change using the Plan-Do-Study-Act cycle.6 The completed appointment card was stapled to an envelope that contained all the patient’s discharge paperwork. The assigned RN reviewed this appointment card with the patient and family and emphasized the reason for and importance of going to this follow-up visit. Educational sessions describing the need for the change, the change, and the new process were held for unit staff RNs, float staff RNs, and the clinical support assistants.The project manager reviewed the number of appointment cards used in the first 2 weeks and found that not all patients with HF were receiving the card on discharge from the hospital. In response, the project manager gave weekly verbal reminders for an additional month, while on rounds, to the clinical support assistants and staff RNs.The outcomes of 7-day appointments scheduled, kept appointments, and 30-day readmissions before change implementation (April to June 2017) and after (July to September 2017) were compared. Benchmarks of 71% for the 7-day appointments scheduled and 50% for kept appointments were set based on the benchmark used by the HF patient navigator team, which consists of physicians, nurses, and pharmacists, at the practice setting. Many variables can affect 30-day readmission, so the benchmark was set to be equal to or less than the national rate. A benchmark of 100% was set for all best practices to be included in the 7-day appointment.We provided an executive summary to the practice setting leadership, and a project abstract was submitted for presentation at the project setting annual science symposium.The 7-day follow-up appointment cards were implemented in July 2017 for patients on our unit who had a primary diagnosis of HF. A total of 35 patients with HF were discharged from this unit between July and September 2017. Sixteen of the 35 patients (46%) were discharged to a skilled nursing facility; they were not included in the follow-up.Of the 19 patients discharged to home, 13 (68%) were older than age 60 years, 14 (74%) were male, and 11 (58%) were white. Insurance sources were as follows: Medicare (n = 13; 68.42%), Medicaid (n = 4; 21%), and private insurance (n = 2; 11%).Table 2 lists the comparison of pre- and postimplementation followup appointments made and kept, and the 30-day readmission rate. The number of 7-day appointments made increased by 15% from the pre- to postimplementation period and there was a 46% increase in the number of patients who kept their 7-day appointment. During the same period, the 30-day readmission rate decreased by 7%.The questionnaire to measure provider adherence to best practices at 7-day follow-up visits was completed by a cardiologist from each of the 2 cardiology groups who saw most of the patients who kept their appointments. According to the data collected from the questionnaires, providers were using 100% of recommended elements for HF follow-up visits.Introduction of an appointment card stapled to envelopes containing patients’ discharge papers was an effective strategy for increasing scheduled 7-day appointments and kept appointments for patients with HF who were discharged from our unit. Benchmarks for scheduled 7-day appointments and kept appointments were exceeded. We think it is probable that the observed 7% decrease in 30-day readmissions was related to this practice change because more patients kept their 7-day appointments and their providers followed best practices for outpatient HF management. A similar decrease in 30-day HF readmission rates after increasing 7-day follow-up visits has been reported in other studies.3,8–10During this project, we encountered several challenges. The first was with the clinical documentation system. In the planning phase of this project, a request to implement an automatic computer pop-up to alert the clinical support assistant and RNs to schedule a follow-up appointment was denied because of limitations of the system. Thus, use of an appointment card was implemented to improve the process of making and encouraging patients to keep 7-day follow-up appointments.The second challenge was related to sustaining use of the appointment card. Staff RNs supported use of the card because the new process saved them time; however, there was some resistance from the clinical support assistants, who had to make the appointment, fill out the appointment card, and staple it to the discharge envelope. During the first 2 weeks after the change, some patients did not receive an appointment card because the clinical support assistant forgot to fill it out and the RN did not realize the card was missing. This process error was corrected by the weekly reminders about the new process from the project manager for an additional month to clinical support staff and RNs. Once the process was sustained for 4 months on our unit, a similar process was rolled out to the other units in our facility.Nurse-driven improvements to the process for scheduling the 7-day postdischarge appointment and patient instructions were successful in this small test of change. Nurses and other providers using a systematic process can be effective in encouraging patients to attend postdischarge appointments. In our study, this process resulted in a reduction in patient readmissions related to HF.The authors thank Ann Marie White, RN, Erica Miska, MSN, RN, and Marit Planton, BSN, RN, for help with tracking and trending outcomes; Nicole Simpson, MSN, RN, for unit support; Opal Smith BSN, RN, and Chantae Hamilton, clinical support assistant; and the Jonas Nurse Scholars Program.