Date of Conferral



Doctor of Nursing Practice (DNP)




Catherine Garner


The rate of hospital readmissions within 30 days of discharge of heart failure (HF) patients affects patient outcomes, the financial stability of the health care facility, and the economy. Hospitals focus on strategies that will decrease the HF readmission rates by cultivating evidence-based interventions that improve patients' transition from the hospital to the community, including promoting self-management of their condition. The purpose of this quality improvement project was to develop, implement, and evaluate the use of health information technology along with written forms of plans of care to assist HF patients in managing their care, divert the HF patients to the physician's office rather than the emergency room, and decrease the hospitalization readmission rate within 30 days of discharge. A multidisciplinary team consisting of HF nurses, a cardiologist, and a pharmacist, utilized the Agency for Healthcare Research and Quality guidelines to develop a HF checklist to assist in data collection. Nurses communicated with HF patients post discharge using electronic devices to reinforce discharge instructions, assess medication compliance, and encourage self-management. The less than 30-day readmission rate for the 10 patients in the pilot group was 20%, an improvement over the hospital rate of 30%. The 20% that were readmitted did not used their written discharge instructions, but the 80% that were not readmitted used their written discharge instructions with their electronic devices. This DNP project will promote positive social change by improving HF patients' outcomes and quality of life, and present health care provider interventions to decrease HF hospital readmission rates.

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