Loading...

Media is loading
 

Affiliations

Advocate Sherman Hospital

Presentation Notes

Evidence Based Practice poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.

Abstract

Background

Hospital readmissions after Acute Myocardial Infarction (AMI) are common and costly, with nearly one in six patients readmitted within 30 days. These admissions contribute significantly to healthcare expenses. Since 2012, hospitals have faced financial penalties for high 30-day readmission rates under the CMS Hospital Readmissions Reduction Program.

Purpose

The project aimed to identify gaps in the discharge process and implement strategies focused on nurse education, patient instruction, early follow-up appointments, follow-up calls, and transition-of-care planning to reduce AMI readmissions.

Implementation Strategies

All cardiac nurses were surveyed to assess current discharge practices. One-on-one education was provided using AHA guidelines and Epic system references. Post-intervention surveys evaluated improvements in knowledge and use of the teach-back method to enhance patient understanding.

Evidence based Recommendations

Patient Education

Education began during hospitalization and continued post-discharge. Nurses used the teach-back method along with printed materials, including discharge summaries, self-management plans, PCI instructions, and medication guides.

Follow-Up Appointments

Appointments with cardiologists or primary care providers were scheduled within 7–10 days post-discharge. Discharge staff coordinated these visits before patients left the hospital. Uninsured patients were referred to a VNA clinic for continuity of care.

Follow-Up Calls

Within 48–72 hours post-discharge, nurses conducted structured follow-up calls using a standard template to clarify instructions and address concerns. Calls helped identify and resolve issues early, preventing readmissions.

Transition of Care

All AMI patients were enrolled in cardiac rehabilitation before discharge and educated on the program’s benefits. Cardiac rehab supported recovery and encouraged adherence to treatment plans.

Results and Conclusion

Readmission rates dropped to 9.1% by September 2024, below the target of 9.74%. Structured discharge education, follow-up planning, and care coordination effectively reduced readmissions and improved patient outcomes.

Document Type

Poster

Publication Date

11-12-2025


 

Share

COinS
 
Nov 12th, 12:00 AM

Heart Matters: Strategies to Decrease Acute Myocardial Infarction Readmission

Background

Hospital readmissions after Acute Myocardial Infarction (AMI) are common and costly, with nearly one in six patients readmitted within 30 days. These admissions contribute significantly to healthcare expenses. Since 2012, hospitals have faced financial penalties for high 30-day readmission rates under the CMS Hospital Readmissions Reduction Program.

Purpose

The project aimed to identify gaps in the discharge process and implement strategies focused on nurse education, patient instruction, early follow-up appointments, follow-up calls, and transition-of-care planning to reduce AMI readmissions.

Implementation Strategies

All cardiac nurses were surveyed to assess current discharge practices. One-on-one education was provided using AHA guidelines and Epic system references. Post-intervention surveys evaluated improvements in knowledge and use of the teach-back method to enhance patient understanding.

Evidence based Recommendations

Patient Education

Education began during hospitalization and continued post-discharge. Nurses used the teach-back method along with printed materials, including discharge summaries, self-management plans, PCI instructions, and medication guides.

Follow-Up Appointments

Appointments with cardiologists or primary care providers were scheduled within 7–10 days post-discharge. Discharge staff coordinated these visits before patients left the hospital. Uninsured patients were referred to a VNA clinic for continuity of care.

Follow-Up Calls

Within 48–72 hours post-discharge, nurses conducted structured follow-up calls using a standard template to clarify instructions and address concerns. Calls helped identify and resolve issues early, preventing readmissions.

Transition of Care

All AMI patients were enrolled in cardiac rehabilitation before discharge and educated on the program’s benefits. Cardiac rehab supported recovery and encouraged adherence to treatment plans.

Results and Conclusion

Readmission rates dropped to 9.1% by September 2024, below the target of 9.74%. Structured discharge education, follow-up planning, and care coordination effectively reduced readmissions and improved patient outcomes.

 

To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.