January 1, 2019BMJ Open QualityOpen Access

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

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Why the study?

Although early post-discharge follow-up is critical to reducing 30-day CHF readmissions, implementation strategies remain challenging in resource-limited settings.

Does a quality improvement initiative focusing on early follow-up and risk stratification reduce 30-day readmissions and mortality in veterans with heart failure?

Structured PICO

Does a quality improvement initiative focusing on early follow-up and risk stratification reduce 30-day readmissions and mortality in veterans with heart failure?

Population

Veterans with congestive heart failure (CHF) discharged from the hospital

Intervention

Two-part quality improvement initiative: 1) provider education on heart failure discharge and early follow-up, and 2) risk stratification (FIRST tool) and electronic medical record (EMR) modifications

Comparator

Baseline period (2012-2013) prior to the intervention

Outcome

7-day follow-up rate, average time to follow-up, 30-day readmission rate, and 30-day mortality ratehard clinical

A resident-driven quality improvement initiative focusing on early follow-up and risk stratification successfully reduced time to follow-up and 30-day readmissions in veterans with heart failure.

Implication

Supports early HF follow-up to curb readmissions in veterans; hypothesis-generating for resource-limited QI and needs RCT confirmation.

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 ( F ailure I ntervention R isk S tratification T ool) 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.