Cardiology & Vascular Research


Implementing the Get with the Guidelines - Heart Failure Tools to Improve Transitional Care Efficiency

Madeline Gervase.

Background: Heart failure readmissions have identified an inadequate structured program following discharge. Incorporating transitional care processes has improved patient outcomes and quality care [1].

Local Problem: A thirty chart audit of heart failure patients was conducted. Only 12 (40%) had documentation that indicated the reason for readmission. Of the 30 patients, three (10%) had documented heart failure education. The aim of this project was to decrease 30-day readmission rates by integrating transitional care tools into Long Term Care (LTC) during a 90-day period.

Methods: Every two weeks, rapid cycle quality improvement using plan-do-study-act cycles were performed. Cycles evaluated team and patient engagement, right care for medication reconciliation, and screening. Data was monitored using run charts.

Interventions: Surveys and tools were provided to promote change. The primary toolkit utilized was the American Heart Associations, Get with the Guidelines – Heart Failure [2]. Team engagement meetings, shared decisionmaking (SDM) processes with patients, screening, and medication reconciliation were implemented.

Results: Routine team meeting attendance was challenging, but staff were engaged at 77%. Right care for heart failure screenings was achieved at 82%, with utilization of the SDM process at 75%, and medication reconciliation was met at 100%. Readmission rates decreased by 75% following a 90-day utilization of the tool.

Conclusion: Implementation of the Get with The Guidelines - Heart Failure toolkit [7] decreased overall readmission rates. Although improvement in all quality measures were noted, there was concern that some may not continue to be sustained due to staffing and scheduling issues.

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