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BMJ Quality Improvement report
Putting veterans with heart failure FIRST improves follow-up and reduces readmissions
  1. Serena Michelle Ogunwole1,
  2. Jason Phillips2,
  3. Amber Gossett3,
  4. John Richard Downs4
  1. 1Internal Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
  2. 2Department of Cardiology, South Texas Veterans Health Care System, University of Texas Health Science Center, San Antonio, Texas, USA
  3. 3Clinical Pharmacology, South Texas Veterans Health Care System, San Antonio, Texas, USA
  4. 4Hospital Medicine Section, Department of Medicine, South Texas Veterans Health Care System, University of Texas Health Science Center, San Antonio, Texas, USA
  1. Correspondence to Dr Serena Michelle Ogunwole; michelle.ogunwole{at}gmail.com

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.

  • quality improvement
  • graduate medical education
  • hospital medicine
  • chronic disease management

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2018-000386

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    Footnotes

    • Patient consent for publication Not required.

    • Contributors SMO and JP contributed to the design and implementation of the research. SMO, JP, AG and JRD contributed to the analysis of the results and to the writing of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Ethics approval This project was deemed quality improvement by the Institutional Review Board at University of Texas Health San Antonio and received an exempt status.

    • Provenance and peer review Not commissioned; externally peer reviewed.