Implementation of an Evidence-Based Practice Discharge Medication Protocol for Heart Failure Patients to Reduce 30-Day Readmissions

Abstract

Practice Problem: An estimated 6.5 million American adults ≥20 years of age have heart failure (HF) and worldwide 1 to 2% of the total healthcare budget is spent on HF. To improve outcomes and streamline the treatment of HF patients, The American Heart Association (AHA) joined with the American College of Cardiology (ACC) and created the Get With The Guidelines Program (GWTG). PICOT: The PICOT question that guided this project was in adult HF patients admitted to the cardiovascular unit under the care of the hospitalist service, does implementing an evidence-based practice (EBP) discharge medication protocol for physician use based on the AHA GWTG program’s HF discharge medication protocol, compared to no standardized discharge protocol, improve patients’ 30-day readmission rate, in 12 weeks? Evidence: Evidence from 10 studies supported implementing an evidence-based GDMT tool into a standardized HF discharge medication protocol for this project. Intervention: Education and encouragement of use of the AHA GWTG discharge medication protocol for HF in the electronic health record (EHR) was provided to a group of physicians on a cardiovascular unit. The intervention was over a four-week period and preand post-intervention protocol use was observed with specific measures analyzed for observation of improvement. Outcome: The results determined there was minimal statistical significance, however, there was a decrease in the financial measure of the cost of HF readmissions denoting a clinical significance. Conclusion: Continued use of a guideline-based discharge medication protocol, such as the one utilized in this project, is recommended based on the results and evidence provided in this project. IMPLEMENTATION OF DISCHARGE PROTOCOL 4 Implementation of an Evidence-Based Practice Discharge Medication Protocol for Heart Failure Patients to Reduce 30-Day Readmissions Patients are diagnosed every day with heart failure (HF), a prominent form of heart disease. Since HF is a complex syndrome, it requires a multidisciplinary approach to assist in decision-making for each patient s treatment plan. To improve outcomes and streamline the treatment of HF patients, The American Heart Association (AHA) joined with the American College of Cardiology (ACC) and created the Get With The Guidelines Program (AHA, 2018). The program is used by hospitals to improve heart disease patients care by promoting consistent adherence to the latest scientific treatment guidelines (AHA, 2018). This paper will evaluate the effects of utilizing a guideline-based discharge medication protocol within the patient’s electronic medical record (EMR) for the discharging provider. This evidence-based practice (EBP) change was intended to improve the outcomes for HF patients as an integral part of their comprehensive discharge plan. Utilizing a systems-level approach to affect change in a healthcare organization may translate the knowledge that exists supporting guideline-based HF management into standard discharge practice. Decreasing variation at discharge for HF patients by implementing a standardized discharge protocol has been associated with a better quality of care and decreased readmission rates (Basoor et al., 2013; Smith et al., 2020). Hospitalization is an opportunity to optimize HF therapy because it gives the physician a chance to consult with patients about the importance of adherence to HF medication and of regular monitoring (Cowie et al., 2017). The DNP project’s goal is to implement the discharge protocol to reduce 30-day readmission rates for HF-related causes. IMPLEMENTATION OF DISCHARGE PROTOCOL 5 Significance of the Practice Problem HF is a chronic, progressive condition in which the heart muscle cannot pump enough to meet the body s blood and oxygen needs (AHA, 2017). An estimated 6.5 million American adults ≥20 years of age have HF (Benjamin et al., 2018 p. 7). The financial impact is enormous. Worldwide, 1 to 2% of the total healthcare budget is spent on HF (Lesyuk et al., 2018, p. 1). It is one of the most frequent causes of hospitalization and accounts for more than $30 billion of United States (US) healthcare expenditure annually (Reddy & Borlaug, 2019). The early post discharge period is a particularly high risk time that often leads to poor outcomes (Smith et al., 2020). An average of 22.3% of HF patients are readmitted to the hospital within 30 days at a mean cost of $14,631 per patient (Kilgore et al., 2017, pp. 65-66). At discharge, patients are often prescribed numerous medications and must make drastic lifestyle changes to improve their HF symptoms and outcomes. Also, there may be multiple comorbidities to be managed alongside the diagnosis of HF (Albert & Kozinn, 2018). The Affordable Care Act of 2010 recognized this as an essential issue (Affordable Care Act, 2010). The legislation instituted a program to reduce the readmission rates of conditions such as HF by penalizing providers for higher-than-average readmission rates. HF hospitalization is a severe burden on healthcare, consuming significant healthcare resources, inflicting substantial morbidity and mortality, and critically impacting the patient s quality of life (Cowie et al., 2017; Yancy et al., 2018). It is prudent for healthcare organizations to seek the best options to increase reimbursement for HF patients. These strategies must decrease the high cost for readmission and provide the best outcomes for patients. In the state of Florida, hospitalizations for HF among Medicare-eligible persons aged >65 years were 38, 347 in 2016 (CDC, 2016). In comparison, over 1,747 people in Duval County, IMPLEMENTATION OF DISCHARGE PROTOCOL 6 Florida, were hospitalized in 2016 due to HF (Florida Department of Health, 2019). The hospital setting for the Doctor of Nurse Practice (DNP) project has identified a significant issue with increased readmissions of HF patients from 26.3% in 2019 to 28.2% in the first quarter of 2020 (D. Stiffler, personal communication, May 2020). Currently, the organization where the EBP occurred has an A rating on the national Leapfrog annual survey of healthcare providers (The Leapfrog Group, 2020). An area of improvement identified as “well below the national average” is communication about medication (The Leapfrog Group, 2020). Implementing the use of a structured discharge medication protocol such as the AHA HF discharge medication protocol, in the EHR allowed physicians to initiate, add, and adjust medications before discharge. This change was intended to help patients achieve optimal therapy, reduce the chance of costly readmissions, and lead to better quality outcomes. An associated physician-led conversation with patients at discharge about the medication inclusion, combined with nursing’s reinforcement of the education at discharge sought to improve the organization’s medication scores on the Leapfrog survey.