Discharge from Hospital to Home: Implementation and Use of the AHRQ IDEAL CHF Discharge Planning and AHA CHF Discharge Checklist

Section I: Abstract Problem: Hospital readmission rates in the congestive heart failure (CHF) population is a quality concern. As excessive readmissions tend to indicate low quality of care, government and private healthcare payers are increasing their focus on 30-day readmission rates as a new quality measure for hospitals. Context: This was a quality improvement project for a telemetry unit at a medical center in the Central Valley of California. There are 56,551 members in the Central Valley enrolled in the healthcare provider system and 2,567 patients with a primary or secondary diagnosis of CHF. Within the healthcare system, CHF was identified as the third most-admitted diagnosis to the telemetry unit, with an average stay of 5.4 days. Interventions: A multifaceted, evidence-based model was implemented using several interventions: (1) TeamSTEPPS Pre-Training Knowledge Assessment survey to gauge nurse CHF knowledge, (2) Agency for Healthcare Research and Quality IDEAL discharge planning resource, and (3) American Heart Association CHF discharge checklist. Measures: The goal of the project was to reduce the 30-day readmission rates for recently discharged patients from a baseline of 14% to 10% by July 2021, with a focus on the discharge education given to the patients and their family members. Results: Initially, there was a high level of interest and engagement among the nurses in educating the CHF patients and gauging their readiness for discharge. As the project progressed, nurse engagement faltered, with nursing staff reporting burn-out and increased stress from multiple improvement projects being implemented simultaneously. Patient feedback concluded that the discharge education provided by the nursing staff was beneficial and increased their comfort being discharged home to self-care. Due to time constraints with the project deadlines, the patient readmission rates could not be accurately assessed; although, results are expected to improve with the continuation of the education introduced during the project. Conclusion: Staff education on the available resources to assist them with CHF discharge education may increase the readiness of CHF patients to discharge home and reduce the 30-day readmission rates in the CHF patients on the telemetry unit in the Central Valley of California. Keywords: congestive heart failure, readmission, education, best practices, discharge planning, self-managemen