P: The population is the nursing staff.
I: The Intervention will be to Implement an evidenced-based standardized heart failure protocol that uses staff education, discharge planning, medication management, and telephone follow-up.
• C: No formal training program and protocol for nurses to follow up on heart failure patients
• O: Increased knowledge of nurses to educate patients and decrease hospital readmissions for heart failure patients.
Will implementing an individualized patient education HF self-care management toolkit protocol which uses standard workflow/ discharge planning, medication management with telephone, dietary sodium /fluid adherence, daily weight measurements, smoking cessation, symptom monitoring, and physical activity follow-up reduce HF readmission and mortality rates in a house call practice?
Needs Assessment and Description of Project
This author has engaged in conversations with several members of nursing leadership within the hospital system in which she is currently employed. The Chief Nursing Officer of the housecalls indicated that heart failure readmissions remain a stubborn problem for the housecalls despite efforts to impact such readmission rates (J. Malaskovitz, personal communication, January 12, 2018).
The director of the housecalls education and training center agrees that a heart failure training class for nurses is needed and would benefit the entire system (N. Carter, personal communication, various dates, 2018). Additionally, during nursing orientation classes for newly hired RNs/LVNs, this author conducted an informal poll asking how many of the nurses feel comfortable with their knowledge level and ability to deliver effective heart failure discharge instructions to their patients. This was done over the course of 8 consecutive weeks, and only 5 nurses out of 150 (3.3%) indicated that they feel confident in their ability to deliver such education.
These conversations along with evidence found in the literature show that this project is needed and will prove to be an integral step to filling this gap and eventually impacting heart failure readmission rates within the hospital system.
The population that will benefit most from this intervention is heart failure patients who have been admitted to an acute care hospital for either a new diagnosis of heart failure or an exacerbation of pre-existing heart failure. Improvements in the knowledge of heart failure self-care principles in this population have been shown to improve adherence to optimal treatment, improve quality of life, and reduce the likelihood of being readmitted once discharged from an acute care
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