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JCOM Abstract

J Clin Outcomes Manage 
2012 Oct;19(10):460-464
Preventing avoidable heart failure readmissions: the University Hospital experience
Raborn N

Abstract Objective: To describe the implementation of a multidisciplinary hospital intervention designed to improve patient outcomes and reduce heart failure readmission rates. Methods: A registered nurse “discharge advocate” worked with heart failure patients using the Re-Engineered Discharge (Project RED) model. Patients received education on self-management of heart failure including dietary recommendations, fluid restriction, medications, and medical management. The discharge advocate collaborated with a multidisciplinary team to ensure the discharge process ran smoothly and the patient was referred to proper services upon discharge. Telemonitoring of patients commenced 2 to 3 days post discharge. Results: Patients receiving the Project RED intervention had a 61% reduction in readmissions compared with those receiving usual care. Conclusion: The use of a nurse discharge advocate in collaboration with a multidisciplinary team improved patient outcomes and reduced the 30-day readmission rate for heart failure patients

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