Doctor of Nursing Practice (DNP) Projects

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Open Access

Degree Program

Doctor of Nursing Practice

Degree Track

Post Master's DNP Completion

Year Degree Awarded



Month Degree Awarded



readmission, transitional care, cardiac surgery, discharge planning, health literacy, and teach-back


Dr. Terry Black, DNP, MBA, CRRN, FAHA, FAAN

DNP Project Chair

Dr. Terry Black, DNP, MBA, CRRN, FAHA, FAAN

DNP Project Member Name

Dr. DeMartinis, PhD, FNP-C

DNP Project Outside Member Name

Dr. C. Mack, III



Background: Readmissions after cardiac surgery are often preventable, costly, and potentially life-threatening events. Hospital readmissions may be influenced by low health literacy and ineffective transitional care. The Centers for Medicare and Medicaid Services have included reducing hospital-bundled payment for frequent occurrence of readmissions and episodic care after coronary artery bypass grafting in 2017. Purpose: This Quality Improvement project explored the impact of applying the STAAR initiative to reduce unplanned readmissions, and to provide safe transitional care in post-cardiac surgery patients. Design/Methods: This was a QI project design with educational and observational methods. The DNP student used the transitional-care toolkit by applying the process of the Plan-Do-Check-Act cycle. Implementation Plan/Procedure: Application of the STAAR initiative as a transitional-care program provided a patient-centered approach. Participants were recruited from the patients' cardiac surgery log who met the inclusion criteria from October 2, 2017 to January 2, 2018 at a tertiary facility in New York City (NYC). Quantitative and qualitative data analyses were compared and analyzed as to whether the STAAR interventions have an impact in providing safe transition and reducing unplanned readmission. Results/Interpretations: After 3 months of implementing the STAAR initiative, the readmission rates were lowered from 16.3% to 5%. A z-test, one-tailed yielded at p < 0.05 value, which was statistically significant. Implications/Conclusions: The Advanced Practice Nurse was successful in supporting the transitional-care program. Education was the key of the transitional care. It improved heath literacy, increased medication adherence, and it lowered unplanned readmission.

Keywords: readmission, transitional care, cardiac surgery, discharge planning, teach-back, and health literacy.

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

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