Date of Graduation

Winter 12-14-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Nancy Taquino

Second Advisor

Dr. Cathy Coleman



Problem: Heart failure (HF), also known as congestive heart failure (CHF), is the number one diagnosis-related group (DRG) for people 65 years of age and older in the United States. This disease group is complicated and debilitating, requiring frequent hospitalizations with high mortality rates. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has identified CHF as an area for improvement in hospitals.

Context: This was a quality improvement project for an integrated medical center in the Central Valley, California with over 19,000 HF patients. In 2018, for patients 65 years and older, HF is the third-most admitted DRG in the hospital, with an average length of stay of 4.3 days.

Interventions: A multifaceted educational model was developed with many interventions: 1) Patient educational handout for HF, 2) Patient teach-back discharge education, 3) RN staff education for HF, 4) RN checklist for HF, 5) HF web page, and 6) Referral workflow of HF patient to the chronic care department for follow-up after discharge.

Measures: The aim of the project is to reduce HF 30-day post-discharge re-admission rates from 6.8% to 4% by December 2018, by focusing on the discharge education to the patients and caregivers. Using 2017 as a baseline, with 311 discharges and 21 (6.8%) re-admissions, the goal for 2018 would be 12 re-admissions, a reduction of 8.7 patients.

Results: There is consistency by the nursing staff in educating a discharging HF patients. Patients state that the discharge instructions for HF are beneficial. Attendance to the heart failure basic class after patient discharge has improved. Due to time constraints with the project deadlines, the patient re-admission rates have not improved as projected since the implementation of the model. The results are expected to improve over the next few months.

Conclusion: There are some important implications for nursing practice from this HF quality improvement project. Nurses require education to give education. Discharge instructions are imperative. Patients need discharge instructions written at a reading level that is easy to understand. Teach-back is a technique in education that improves the patient’s comprehension. Checklists provide consistency in nursing practice to ensure all steps are followed in fast-paced hospital discharges. Follow-up for a patient within a short time from discharge is well received by the patient. The educational model design can be transferable for other commonly admitted chronic conditions.

Patients being readmitted routinely for HF generally have been in the later stages of the disease process. Few patients are not involved with the palliative care team. Many of the patients and their families have not considered end-of-life decisions, including code status for admissions. The next phase of this project will involve palliative care intervening in the plan of care for the chronic HF/CHF patient.

Sustainability is a process and competing priorities make it difficult to achieve improvements as expected in the planned timeline. Quality improvement projects evolve over the process, and new insights are gleaned and can change the focus or aim of the project.