Date of Doctor of Nursing Practice Project Completion
Summer 8-1-2026
Faculty Advisor
Dr. Debbie McCrea, EdD, MSN, APRN, FNP-BC, CNS, CNE, CEN, CFRN, EMT-P
Abstract
Purpose: The purpose of this quality improvement (QI) project is to reduce 30-day readmissions for adult patients with heart failure (HF) by implementing a standardized HF pathway beginning in the intensive care unit (ICU) and continuing through discharge.
Background: The project was implemented within a large healthcare organization in Northwest Houston, Texas.
Methodology: This project utilized a pre- and post-implementation design guided by the Plan-Do-Study-Act (PDSA) model. Eligible adult patients (≥18 years) with a primary or secondary HF diagnosis were identified during March 2026. The My Pathway to Wellness HF education pathway was initiated at the time of ICU downgrade and continued through discharge, with bedside MyChart activation, and 7-day follow-up scheduling with a HF Advanced Practice Provider (APP) or a cardiologist. Process measures included pathway utilization, MyChart activation, follow-up scheduling and attendance, and 30-day HF readmissions.
Results: Of the 77 eligible HF patients, nine received the interventions. Among intervention patients, 88.9% completed MyChart activation, 44.4% had a 7-day follow-up scheduled, and 33.3% attended the follow-up appointment. Two patients (22.2%) were readmitted within 30 days, including one ICU readmission and one non-ICU readmission. The ICU HF 30-day readmission rate was 11.1%. Two patients receiving HF APP-led transition-of-care (TOC) follow-up were not readmitted. Eighteen ICU nurses completed the survey, with 66% reporting that the pathway was easy to integrate into their workflow. Although the readmission target was not achieved, the findings demonstrated promising outcomes and the feasibility of implementation.
Implications: Implementation of a standardized HF transitional care pathway initiated in the ICU has the potential to improve care continuity, strengthen patient self-management, and reduce preventable readmissions. These findings highlight the importance of interdisciplinary collaboration among nurses, case managers, and providers in supporting effective care transitions. Long-term sustainability will require ongoing staff education, leadership support, routine performance monitoring, and continuous feedback to ensure consistent pathway implementation across inpatient units.
Keywords
heart failure, transitional care, quality improvement, acute care, 30-day readmission, nurse-led intervention
Recommended Citation
Thuy Nhu Uyen Tran, "Enhancing Heart Failure Transitional Care to Reduce 30-Day Readmission Rate" (2026). Doctor of Nursing Practice Final Project Abstract. 213.
https://digitalcommons.library.tmc.edu/dnp_abstract/213
Included in
Critical Care Nursing Commons, Other Nursing Commons, Quality Improvement Commons, Telemedicine Commons