Doctor of Nursing Practice (DNP) Projects

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Open Access

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Embargo Period

5-15-2014

Degree Program

Doctor of Nursing Practice

Degree Track

Family Nurse Practioner

Year Degree Awarded

2014

Month Degree Awarded

May

Keywords

transition of care, primary care provider, patients’ readmission, heart failure, post hospital follow up appointment, medication reconciliation

Advisor

Emma Dundon

DNP Project Chair

Emma Dundon

DNP Project Member Name

Joan P. Roche

DNP Project Outside Member Name

Elaine L. Cohen

Abstract

The goal of this quality improvement project was to enhance the transition of care from the hospital to primary care providers for patients with heart failure at one acute care hospital in Tampa, Florida. A literature review revealed that discharge summaries have a pivotal communication role in the transition of care. Consequently, the electronically recorded discharge summaries relating to a random sample of 60 patients discharged from this hospital were audited for a trial period of six months (three months before and three months after an intervention by the DNP candidate to encourage the attending physicians to improve the transition of care.) The following data were collected: (a) the extent to which the discharge summaries complied with the components mandated by the Joint Commission on the Accreditation of Healthcare Organizations (Standard IM.6.10, EP 7); (b) the extent to which six specified outcome indicators reflecting a high level of transition of care were implemented; and (c) the relative rates of hospital readmission within 30 days after discharge. The readmission rates were reduced by 10% after the intervention. The discharge summaries complied with all the standard components, but were deficient with respect to one indicator. A shortage of clinical pharmacists was associated with more than 10% of the patients not receiving medication reconciliation within 24-48 hours after discharge. Consequently, recommendations are made to expedite the process of medication reconciliation.

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