Putting veterans with heart failure FIRST improves follow-up and reduces readmissions

Abstract

Background: Despite improvements in length of stay and mortality, congestive heart failure (CHF) remains the most common cause of 30-day readmissions to the hospital. Though multiple studies have found that early follow-up after discharge (eg, within 7 days) is critical to improving 30-day readmissions, implementation strategies are challenging in resource-limited settings. Here we present a quality improvement initiative aimed at improving early follow-up while maximising available resources.

Methods: This was a medical resident-driven initiative. A process map of the discharge and follow-up appointment process was created that identified multiple areas for improvement. Based on these findings, a two-part intervention was implemented. First, heart failure discharge education with focus on early follow-up was disseminated to providers throughout the internal medicine department. Subsequently, improved identification of high-risk patients (Failure Intervention Risk StratificationTool) and innovative use of the existing electronic medical record (EMR) were employed to sustain and improve on gains from the first set of interventions.

Results: We increased our 7-day follow-up rate from 47% to 57% (p=0.429) and decreased the average time to follow-up from 17.6 days to 8.7 days (p=0.016) following the first intervention. The percentage of patients readmitted within 30 days after discharge at baseline (2012-2013) and following the first intervention (education and standardisation of follow-up scheduling) and second intervention (risk stratification, intensive follow-up and EMR change) was 25% and 21%, respectively. Thirty-day mortality rate decreased from 10% in 2011 to 7.16% in December 2015.

Conclusion: Close hospital discharge follow-up and identification of high-risk patients with CHF are useful approaches to reduce readmissions. Using the existing EMR tool for identifying high-risk patients and improving adherence to best practices is an effective intervention. In patients with CHF these strategies improved time to follow-up and 30-day readmissions while decreasing mortality.

Keywords: chronic disease management; graduate medical education; hospital medicine; quality improvement.

Figure 1

Process map of discharge work flow before intervention.

Figure 2

Cause and effect diagram for the problem of delayed discharge.

Figure 3

Control chart with split control limits before and after intervention. LCL, lower control limit; UCL, upper control limit.