Karen Weeks, DNP, RN, CCRN-K, is a graduate of Doctor of Nursing Practice at James Madison University. This article is her DNP project. She is a nursing instructor in the undergraduate nursing program at James Madison University. Karen's clinical and research interests include exploring challenging issues that impact the health care system with highly complex patient populations.
Debbie Kile, DNP, RN, NE-BC, serves as a quality improvement coordinator. She earned her Doctor of Nursing Practice degree from James Madison University. Debbie's clinical and research interests include improving quality of care and creating positive work environments for nurses.
Prof Case Manag. 2020 Nov/Dec;25(6):343-349. doi: 10.1097/NCM.0000000000000437.
PURPOSE/OBJECTIVES: The purpose of this quality improvement project was to evaluate the impact of a nurse discharge navigator on reducing 30-day readmissions for the heart failure and sepsis populations.
The 238-bed community hospital in central Virginia is part of a health care system that encompasses 13 acute care facilities.
The aim of this project was to identify, implement, and evaluate the transition of care of high-risk readmission patients from January 2019 to April 2019. Inclusion criteria included patients who were 55 years and older, English speaking, diagnosed with heart failure and/or sepsis, discharged to home with or without home health, and/or consults received from case management and social services. Forty-one potential participants were identified with 28 consented. Readmission data were collected pre- and postintervention. The pre-/postanalysis consisted of descriptive statistics, readmission rates, and cost avoidance.
Out of the 28 participants, 7 participants were readmitted within 30 days. The heart failure readmission rates during the project implementation were as follows: January 24.05%, February 20%, March 19.75%, and April 11.11%. After the project completion the readmission rates were 22.97% for May and 26.03% for June, respectively. The potential cost avoidance with sustained gain from the project is $405,316.00.
This project demonstrated that a discharge navigator had an effect on 30-day readmissions for high-risk heart failure and sepsis populations, as evident by a steady decline in overall heart failure readmission rate during project implementation. The sepsis population needs further research. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination, and education that is needed for these types of patient populations that have a great deal of medical complexity.
目的/目标：本质量改进项目旨在评估护士出院导航员对降低心力衰竭和败血症患者 30 天再入院率的影响。
弗吉尼亚州中部的这家 238 张床位的社区医院是一家医疗保健系统的一部分，该系统涵盖了 13 家急性护理设施。
该项目的目的是确定、实施和评估高危再入院患者从 2019 年 1 月到 2019 年 4 月的过渡护理。纳入标准包括年龄在 55 岁及以上、讲英语、诊断为心力衰竭和/或败血症、出院回家，无论是否接受家庭健康护理，以及/或接受病例管理和社会服务咨询。确定了 41 名潜在参与者，其中 28 名同意参与。在干预前后收集再入院数据。预/后分析包括描述性统计、再入院率和成本避免。
在 28 名参与者中，有 7 名在 30 天内再次入院。项目实施期间心力衰竭的再入院率如下：1 月 24.05%、2 月 20%、3 月 19.75%和 4 月 11.11%。项目完成后，5 月的再入院率为 22.97%，6 月为 26.03%。项目持续带来的潜在成本节约为 405316.00 美元。
该项目表明，出院导航员对高危心力衰竭和败血症患者的 30 天再入院率有影响，这从项目实施期间整体心力衰竭再入院率的稳步下降中可以明显看出。败血症患者需要进一步研究。出院导航员项目为这类具有大量医疗复杂性的患者群体所需的综合出院计划、协调和教育提供了更多的知识。
