Heart Failure Hospital Readmission Assessment: A Tool to Guide Transitional Care

Abstract

Background: Heart failure cost and disease burden are significant (Patel, 2021). Objective: This project implemented a heart failure (HF) hospital readmission risk assessment tool to guide transitional care and decrease HF hospital readmissions. Methods: Sixty-four patients hospitalized with a primary diagnosis of heart failure were evaluated between January 28, 2023, and April 23, 2023. Conclusions: Twenty-two patients met at least one high-risk criterion. Six patients met this criterion based upon a left ventricular ejection fraction (LVEF) of less than 25%. Before discharge, the serum creatinine level rose 30% or more from baseline for nine patients. The number of prior admissions for acute decompensated HF within the last month ranged from zero to three. The New York Heart Association (HF classification was rarely identified, and providers inconsistently documented activities limited by symptoms of HF at the time of admission. Twenty-seven patients had an NYHA classification ranging between I to IV, with an average classification of 3.33. Implications for Nursing: This project identified the need for collaboration between acute care, primary care, and inpatient and outpatient providers. This project also identified the need for the provider to document a more comprehensive review of systems at admission.