This study aims to determine if a nurse-delivered discharge planning bundle that includes a follow-up phone call within 1 week of discharge will decrease rapid readmissions of patients with heart failure. The researchers will implement a discharge care bundle including patient education and a follow-up phone call on a hospital unit. They will compare rates of readmission before and after the intervention to see if the bundle reduces readmissions. The goal is to improve patient outcomes and lower healthcare costs for heart failure patients.

1. Research Methods in Nursing NUR 602
Celeste Connelly, Kelly Gibson,
Ashley McCann Rogers & Amy Squire

2. Introduction
 5.7 million Americans live with heart failure (HF).
 The cost of care of HF patients was $37.2 billion dollars
in 2009.
 Rapid readmission (readmission to an acute care
facility within 30 days of discharge) for Medicare
patients was 26.9% in 2010.
 Management of heart failure consumes more resources
than any other diagnosis….
 We need to improve care and cut costs.

3. Purpose of the Study/Hypothesis
• To determine if a nurse-delivered discharge planning
bundle that includes a follow-up phone call within 1
week of discharge will decrease the rate of unplanned
admissions among patients with a primary or
secondary diagnosis of HF.
• The addition of a follow-up phone call to a discharge
care bundle will reduce the rapid readmission of
patients with HF to the hospital.

4. Procedures
 January 1 – June 30 – Retrospective chart review to determine
number of rapid readmissions conducted by Quality Improvement
Department of a local hospital. IRB approval obtained from
University of North Carolina at Greensboro. Study was deemed
exempt Category #4. All information was de-identified before
included in the study.
 July 1 – September 30 – Staff education/preparation of unit for
introduction of new discharge care bundle that will include HF
patients - #1 admitting diagnosis on the unit
 October 1 – December 31 – Implement the discharge planning
bundle that includes follow-up phone call.
 January 1 – June 30 - Collect data about rapid readmissions
following implementation the new care bundle.

5. Sampling and Setting
 Target Population: Patients hospitalized for HF.
 Setting: An inpatient 20 bed telemetry unit of a local hospital staffed with
30 RN’s/10 CNA’s /4 Monitor Tech’s
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1.
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Inclusion Criteria:
Age 65 or older
Discharge diagnosis of HF (as the primary or secondary diagnosis)
Alert and competent to read, understand and speak English
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1.
2.
3.
Exclusion Criteria:
Skilled Nursing Facility (SNF) patients
Department of Correction residents
Pregnant women
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1.
Protection of Human Rights:
All demographic information was stored on a secure server with
protection by a 2 password system
Patients gave consent to be contacted by telephone following hospital
stay
2.

6. Discharge Care Bundle
 Patients will receive an educational plan that follows the
Self Care of Heart Failure Index (SCHFI) developed in
studies done by Riegel, Lee, Dickson & Carlson (2004).
 Education Concepts/Goals - Self-care maintenance, Self-
care management and Self-care monitoring/confidence.
 The intention of the follow-up phone call is to monitor the
patient understanding of the goals of the program and to
follow their progress as well as answer any questions they
may have. A graduate nurse researcher will attempt to
contact all patients within a week of discharge.

7. Follow-up Phone Call
 Medications:
What medications are you taking and are you taking them as prescribed?
Do you have any questions about your medications?
• Activity:
Are you able to participate in some type of physical activity daily?
 Weight:
Do you weigh yourself daily? Has your weight stayed the same, increased
by > 3# in a day or >5# in a week?
 Diet: Are you following a low sodium diet?
 Symptom Management:
Do your feet/ankles/hands swell? Are you short of breath when you climb
stairs or get dressed in the morning? Are you tired all the time? Can you
participate in your usual activities?
• Follow-up:
Have you seen your primary care provider for your follow-up appointment?
• Can I help you with any other information?

8. Self care of Chronic Illness
A Middle Range Theory
•
•
•
•
Diet
Medications
Exercise
Smoking cessation
Self-care
maintenance
Self-care
monitoring
• Weigh daily
• Monitor B/P HR
• Recognize changes
• Adjust treatment in
response to
changes
• Seek primary care
follow up
Self-care
management

9. Research Approach/Design
 This study will use a Quantitative approach to define if an
enhanced educational program and follow-up phone call
(independent variable) would reduce rapid readmission
(dependent variable) of HF patients after hospitalization.
 This is a Quality Improvement study that will attempt to
show a relationship between the enhanced educational
program and better outcomes for HF patients.
 We will use a pretest/posttest design as we are collecting
information about rapid readmission both before the
discharge planning bundle is initiated and after to
determine the change in rapid readmissions.

10. Outcomes/Statistics
 At the end of our study we will report the number of
readmissions that occurred during the six month period
following the introduction of the discharge planning
bundle.
 Additionally, we may be able to identify any areas of the
educational program that can be improved, indicating
further Quality Improvement opportunities.
 We will employ a graduate student statistician to assist
with the evaluation of the study.

11. Limitations
 We will have a small sample because we have limited
the initiation of the discharge care bundle to one
specific unit in one hospital.
 We have chosen to use a convenience sample which
may limit the ability to apply our findings to a larger
population.
 The discharge planning bundle is being introduced as
a new standard of care but we do not know if the
education is completed or delivered in a consistent
manner with each HF patient.

12. Budget
 Materials /copying fees
 Professional services of statistician
 Total Cost of study
50
500
$ 550

13. Resources
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