EP7EO

 

Interprofessional Care EP7EO

 

Using the required empirical outcomes (EO) presentation format, provide one example of an improvement in a specific patient population outcome associated with nurse’s(s’) participation in an interprofessional collaborative plan of care.

 

 

Example: Nurses’ Participation in an Interprofessional Collaborative Plan of Care Decreased Heart Failure Readmissions

Problem
At Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS), there has been an increased percentage of patients readmitted with heart failure.

 

Pre-Intervention

An increased percentage of heart failure patients were readmitted to the CHI SVHS medical unit 2 East Cardiology (2E). This was a busy season at CHI SVHS with an increased number of flu and respiratory patients. An interprofessional heart failure readmissions workgroup was formed to determine factors, causing an increased readmission percentage of heart failure patients. The team focused on rapid cycle problem solving to address the readmissions problem.

 

The team was led by Vicky Sanders, MSN, RN, CNML, Director of Care Management, and included Kaitlyn Atkins, MSN, RN, CPN, Clinical Director of Nursing; Magen Schaub, BSN, RN, Nurse Manager, 2E; Jessica Bray, BSN, RN, Interim Nurse Supervisor, 2E; Madison Hair, BSN, RN, Interim Patient Care Coordinator, 2E; Judith Felter, MSN, RN, CCRN, Care Coordinator; Megan Savage, MS, OT/L, CBIS, Manager of Therapy Services; Tiffany McCain, PharmD, Director of Pharmacy; Christi Amerson, PharmD, Manager of Pharmacy; John Bouldin, MD, ED Physician, and Shauna Lucas, MD, Physician Advisor. The team identified a lack of patient education, home scales, and timely follow-up as contributing factors to heart failure patient readmissions.

 

From December 17 to 30, 2023, the heart failure readmission percentage on 2E Cardiology was 40%.

 

Goal Statement

Decrease the heart failure readmission percentage on 2E Cardiology.

 

Participants

 

Heart Failure Readmissions Work Group
Name/Credentials	Discipline	Title/Role	Department
Vicky Sanders, MSN, RN, CNML	Nursing	Director of Care Management	Care Management
Kaitlyn Atkins, MSN, RN, CPN	Nursing	Clinical Director of Nursing	Nursing Administration
Magen Schaub, BSN, RN	Nursing	Nurse Manager	2E Cardiology
Jessica Bray, BSN, RN	Nursing	Interim Supervisor	2E Cardiology
Madison Hair, BSN, RN	Nursing	Interim Patient Care Coordinator	2E Cardiology
Judith Felter, MSN, RN, CCRN	Nursing	Care Coordinator	Care Management
Megan Savage, MS, OT/L, CBIS	Therapy	Manager of Therapy Services	Therapy
Tiffany McCain, PharmD	Pharmacy	Director of Pharmacy	Pharmacy
Christi Amerson, PharmD	Pharmacy	Manager of Pharmacy	Pharmacy
John Bouldin, MD	Physician	Physician	Emergency Department
Shauna Lucas, MD	Physician	Physician Advisor	Medical Affairs

 

Description of the Intervention December 31, 2023, to January 13, 2024

• The team developed a zoning tool to educate heart failure patients at risk for readmission. The zones include green zone: goal/all clear, yellow zone: caution/warning, and red zone: medical alert/emergency. The zones correspond to heart failure symptoms and interventions to prevent patients from being readmitted. Patients are encouraged daily to:
  • Weigh themselves in the morning before breakfast, and write it down
  • Take medications as prescribed
  • Check for swelling in feet, ankles, legs, and stomach
  • Eat low salt foods. Avoid canned or packaged foods and read food labels.
  • Balance activity and rest periods
  • Review which heart failure zone corresponds with their symptoms that day. If in the yellow zone, they are instructed to contact their doctor, nurse, or caregiver. If in the red zone, patients are instructed to go to the emergency department or call 911.
• Bray or the bedside RN provides this tool to the patients on day one of their admission and reviews the tool daily to guide them on how to manage their heart failure at home.
• During multidisciplinary rounds (MDR), consultations for specialty services are added to the plan of care discussion among heart failure patients. These consult services included care management, pharmacy, nutrition, therapy, and palliative, APRN as applicable. Bray leads the MDR, directing which patient is next. The primary nurse gives a quick report to MDR participants, including case management, the physician, pharmacy, APRN, supervisor, and clinical documentation improvement. The interprofessional team discusses the needs of the patient and any concerns or changes in condition and collaborates on the plan of care for the patient. Bray is responsible for ensuring all orders are placed, the nurse reads the MDR sheet in completion, and everyone has a chance to share their piece of the puzzle.
• All heart failure patients were given a three-to-seven-day follow-up appointment. The readmission team determined patients seen at the CHI SVHS hospitalist discharge clinic or Medicaid clinic, have a follow-up appointment within three to five days. Bray, the charge nurse, or the primary nurse schedules all appointments. A timely follow-up ensures the patient is following instructions given during their hospitalization, symptoms are addressed to prevent the patient from being readmitted, and the patient is connected to community resources.
• At admission, the admitting clinical nurse encourages all patients to sign up for Meds to Beds. With this program, a pharmacist from Smith Pharmacy goes to the patient’s bedside to confirm the patient receives their medications before discharge and provides appropriate medication education.
• Central Supply gives all patients a scale and a blood pressure cuff at discharge. The discharging nurse ensures they have it at the bedside at discharge for home management of weight and blood pressure tracking.

 

The interventions were fully implemented by January 13, 2024.

 

Nurses’ participation in an interprofessional collaborative plan of care led to an improvement in the specific patient population of heart failure patients by decreasing the 2E Cardiology readmission percentage.

 

References:

Al-Tamimi, M. A.-A., Gillani, S. W., Abd Alhakam, M. E., & Sam, K. G. (2021). Factors associated with hospital readmission of heart failure patients. Frontiers in Pharmacology, 12. https://doi.org/10.3389/fphar.2021.732760

 

Schönenberger, N., & Meyer-Massetti, C. (2023). Risk factors for medication-related short-term readmissions in adults – a scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10028-2

 

Outcome

1. (Evidence EP7EO-1, 2E Heart Failure Patient Readmissions Graph)