Doctor of Nursing Practice (DNP) Projects

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Doctor of Nursing Practice

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Post Master's DNP Completion

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Keywords: Heart failure (HF), transitional care, 30-day readmission rate, long term-care.


Dr Gabriela Abelard DNP, PMHNP-BC

DNP Project Chair

Dr. Pamela PhD, MPH, FNP-BC


Background: Heart failure is the leading cause of hospitalization in the United States and accounts for more than one million hospitalizations every year. Readmission within 30 days of discharge is an indicator used for measuring the quality of care for heart failure patients.

Methods: The goal of this quality improvement project was to reduce the 30-day readmission rate of heart failure patients 60 years and older in a long-term care setting in Texas by using an evidence-based transitional readiness discharge checklist for heart failure. Interventions included staff education on the key components and on the checklist. A pre- and post-test was given to measure staff learning, and the 30-day readmission rate of patients was tracked in the long-term care facility.

Results: The project followed 18 patients with heart failure and other comorbidities admitted between October 2018 and March 2019. None of the 18 patients were readmitted to the hospital within 30 days for heart failure exacerbation, although two were readmitted for other reasons. Following staff education, the readmission rate decreased from a previous high rate of readmission to the hospital from this facility of 45% to 13%. Ten licensed staff reported increased knowledge of HF with pre-test mean scores of 82.78 and post-test mean scores increased to 98.57.

Conclusion: Staff education on discharge readiness checklist of heart failure older adult patients may increase the knowledge of the staff resulting in better care of heart failure patients on discharge from acute care facilities and reductions in the 30-day readmission rate as seen in the heart failure patients at this Texas long term care facility.

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