ANE PICOT 2

Nurse-Led Heart Failure Transitional Care and Hospital Readmissions 1

Nurse-Led Heart Failure Transitional Care and Hospital Readmissions

Nurse-Led Heart Failure Transitional Care and Hospital Readmissions

Student’s name: Anet Hernandez

Florida National University

Instructor: Yesenia Osle

Course: Applied Nursing Research-DAX-DL01

Date: September 15, 2026

Introduction

Heart failure (HF) is a chronic cardiac condition that usually requires hospital treatment and frequent monitoring once released from hospital. Discharge to home may be challenging as it takes time for patients to learn the information about medicines, when symptoms become more severe, how to keep track of their weight, what foods to eat and when to call a health care provider to get help. Patients not receiving the proper support during this time are at risk of exacerbating their symptoms and seeking treatment in an ED or returning to the hospital. Nurses are in an ideal position to take care of patients through this transition as they can provide patient education, evaluate symptoms, teach self-management practices, and communicate with patients’ post-hospitalization.

Some recent research has established the merits of the nurse-led approach to heart failure care. Nurse-led heart failure programs were mostly composed of patient education, transitional care, follow-up on the medication, psychosocial interventions, and telephoning. Nurse-led heart failure programs usually yielded positive results with respect to patients' outcomes. Tian et al. (2024) stated that nurse-led education programs lowered the chances of readmission for heart failure patients by about 25%. It was established that post-discharge follow-up lowers the risk of readmission. The paper attempts to investigate the possibility of implementing a nurse-led heart failure transitional care program for adult patients who have been discharged from the acute-care hospital.

Problem Statement

When patients are discharged from the hospital, readmission is an important issue with patients with heart failure. Patients can go back to the hospital if they have problems with fluid retention, their breathing gets worse, medication problems, problems with their diet, and other problems that may also be identified and addressed at an early stage. This is a critical time to prepare for life post-discharge, as patients are getting used to modifications in medications, their lives, and daily routines while coping with a complex chronic illness at home.

Recent evidence supports the need for the improvement of transitional care. Wilson et al. (2024) found 12 studies to review regarding nurse-led heart failure clinics, and interventions consistently reported included education, transitional care and follow-up, medication management, and providing telephone support. Tian et al. (2024) looked at all the randomized controlled trials in relation to nurse-led interventions and concluded that nurse-led interventions were effective in reducing heart-failure-specific readmissions by 25%. Additional advantages identified during the analysis were home nursing visits and improved quality of life. Another important element is follow-up following discharge. While there were large variations in each study, outpatient follow-up reduced the risk for 30-day all-cause readmission by 21% (Bilicki & Reeves, 2024)

PICOT Question

Among adult patients with heart failure being discharged from acute care hospitals (P), what effect does the provision of daily weight training with regular nurse calls per week (I) have on 30-day readmissions to the hospital (O) when compared with the current discharge procedures (C) Over 12 weeks (T).

Population of Interest

The population of interest is adults diagnosed with heart failure who are discharged from an acute-care hospital to their homes. The proposed project targets these patients because they have a potential for transition from inpatient care into self-management as an independent patient, which can present a large challenge for them. Can include adults with varying heart failure types and stages with good clinical stability for discharge who are able to participate in intervention. Patients and caregivers must be capable of accepting education and involved in weight monitoring every day. Nurses should, however, identify barriers and assess if support, involvement of caregivers, interpreter services, or adaptive education is possible.

The focus would be to work with patients with higher admission risk rates due to past admission(s), poorer medication management, poor understanding of HF symptoms, or poor monitoring behavior. Consideration of individualizing education would enable making the intervention more patient-oriented and more in the real world.

Intervention of Interest

The intervention of interest is a transition program based on standardized nurse-led daily weight education and weekly telephone follow-up for 12 weeks. The nurse/infirmary would educate patients on heart failure self-management prior to discharge, encompassing the need for daily weight checking, taking medication, dietary advice as needed, and symptom awareness and management should symptoms deteriorate.

Unusual weight gain would be emphasized as this may be a sign of higher fluid retention, and weight would be monitored every day. Patients will be given written policies on how to weigh, when to weigh, and how to note down their weight. The nurse's responsibility would be to check on the patient's weight and symptoms in weekly follow-ups. In cases where changes are noted, the nurse would follow the correct process within the healthcare organization that would alert the provider or indicate to the patient the care they are required to take. WU et al. (2024) found that key elements of nurse-led heart failure programs are education, transitional care, follow-up, and telephone consultations. The intervention is viable as it does not need extensive new infrastructure. Implementation for this could be accomplished with a nurse, standardized educational materials, a reliable scale, phone access, and documentation of subsequent contacts.

Comparison of Interest

The usual discharge care without the structured nurse-led transitional care program would be used as the comparison group. Normal management can involve leaving instructions, prescribing drugs, regular follow-up by the provider, and/or traditional education during the hospital stay.

Usual care is an appropriate comparator since it is the care that is received by the patient in the absence of the intervention. Comparing the structured nurse follow-up and usual care would help the project team find a measurable difference in the rate of readmissions associated with the structured nurse follow-up. This is also consistent with recent research. Numerous trials have investigated the effects of nurse-led heart failure intervention. There is some evidence that further transitional support can be beneficial over and above regular care.

Outcome of Interest

The first outcome is 30-day readmission after hospital discharge. Measurable because each participant can be identified as having an unplanned hospital readmission within 30 days of the index hospital discharge. Readmission is appropriate because it is a direct measure of the effectiveness of transitional care and is clinically relevant to patients, providers, providers' organizations, and healthcare systems. The project team could determine the percentage who were hospitalized within 30 days of hospital discharge from the intervention and usual care groups.

For instance, with usual care, 20% of patients are readmitted to the hospital within 30 days of their discharge, and with the nurse-led intervention, the rate drops to 12%. This falls 8 percentage points short of patients receiving the usual medical care. Other outcomes like ED visits, adherence to medications, or cultural knowledge could be measured, but the 30-day re-admission would continue to be the primary quantitative outcome.

Recent findings have supported the use of readmission as an outcome for transitional-care interventions. The interventions provided by the nurse can improve patient outcomes after a heart failure admission, including outcomes that are specific to heart failure; nurse-led interventions reduced the readmission rates for heart failure on its own, and outpatient follow-up.

Timeframe

The projected time to implement is 12 weeks. This time will allow for the intervention to be implemented repeatedly and for the project staff to observe the results through multiple post-discharge cycles. It would be implemented while a person is in the hospital, before they go home. In the first week, the nurse would conduct standardized education to ensure they are able to correctly monitor daily weight. Then weekly telephone follow-up would be initiated through week 12. Thirty-day readmissions after each qualifying discharge would be monitored, and a project team would be able to review 30-day readmission trends throughout the period the project was being implemented.

Conclusion

There are critical issues around leaving hospital and going home for people with heart failure. Poor symptom recognition, medication issues, failure to monitor symptoms, and lack of follow-up can be associated with avoidable health care use. Patients in the sample are adults who are discharged from an acute-care hospital with heart failure. Nursing structured interventions include structured nursing teaching and daily weighing; weekly follow-up within the intervention group, and usual nursing at discharge in the control group.

References

Ahmed, M., Shafiq, A., Zahid, M., Dhawadi, S., Javaid, H., Rehman, M. E. U., ... & Siddiqi, A. K. (2024). Clinical outcomes with nurse-coordinated multidisciplinary care in patients with heart failure: a systematic review and meta-analysis. Current Problems in Cardiology, 49(1), 102041. https://doi.org/10.1016/j.cpcardiol.2023.102041

Bilicki, D. J., & Reeves, M. J. (2024). Outpatient follow-up visits to reduce 30-day all-cause readmissions for heart failure, COPD, myocardial infarction, and stroke: a systematic review and meta-analysis. Preventing Chronic Disease, 21, E74. https://doi.org/10.5888/pcd21.240138

Tian, C., Zhang, J., Rong, J., Ma, W., & Yang, H. (2024). Impact of nurse‐led education on the prognosis of heart failure patients: A systematic review and meta‐analysis. International Nursing Review, 71(1), 180-188. https://doi.org/10.1111/inr.12852

Wu, X., Li, Z., Tian, Q., Ji, S., & Zhang, C. (2024). Effectiveness of nurse-led heart failure clinic: A systematic review. International Journal of Nursing Sciences, 11(3), 315-329. https://doi.org/10.1016/j.ijnss.2024.04.001

Zheng, J., Mednick, T., Heidenreich, P. A., & Sandhu, A. T. (2023). Pharmacist-and nurse-led medical optimization in heart failure: a systematic review and meta-analysis. Journal of cardiac failure, 29(7), 1000-1013. https://doi.org/10.1016/j.cardfail.2023.03.012