Theme: To learn. AR.uthscsa.edu. Evidence: to patient. we should. received and. author(s).

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1 Multifaceted Approach to Reduce 30 Day Heart Failure Readmissions Joan Smith, MS, BSN, RN, CMSRN Pennsylvania Hospital University of Pennsylvania Health System JoAnne Ruggiero, Lauren Durkin, Jacqueline Copeland Problem: Pennsylvaniaa Hospital, an acute care facility primarily serving an elderly population had the highest readmission rates in their health system. Patient demographics within all threee hospitals is similar. Pennsylvania Hospital received a 1% Medicare reduction in payment penalty as a result. Evidence: Congestive Heart Failure (CHF) most common cause of hospital admissions, 1.4 million admitted annually, accounting for $17 billion in total spending. Despitee advances in care, in the first 30 days after hospitalization one in five patients is readmitted. A literaturee review has shown that a multifaceted interventional approach is most effective in reducing readmission rates. Strategy: Our multifaceted approach begins on admission and includes pre, post and transitional discharge care interventions. A CHF liaison was implemented to identifyy and follow all CHF patients eligible for intervention. Interventions included: CHF education class, educational DVD and discharge booklet emphasizing self care strategies and symptom management, evaluation for self care tools, pharmacy consult, post discharge care, medication reconciliation, appointment scheduling, communication with PCP, follow up phone call assessment, and identification of high risk for readmission patients. Practice Change: The heart failure protocol was initiated in Pre discharge intervention included: Patient and family education, discharge planning, medicationn reconciliation, and discharge Time Out process. Post discharge interventions include: follow up appointment within 7 days, PCP written discharge summary, follow up phone call assessment, patient hotline, and home care individualizedd to patient. Evaluation: Primary outcome 30 day readmission rates. Secondary outcomes were protocol compliance, core measure adherence and an increase in home care services. Results: Reduction in CHF readmission rates from 26.44% (2012) to 19.69% (to date). Core measuree adherence 97% to 100% consistently. Those receiving intervention 85% to 90%. Ability to reach patients by phone following discharge approximately 55% %. Willingness to accept home care services extremely low. Recommendations: Ongoing efforts to effectively identify and assess highh risk for readmission patients. Efforts to recognize and remedy patient barriers towards home care services. Lessons Learned: The CHF multi faceted approach was eitherr developed/and or reviewed for content and process by a team of nurses, pharmacists, nutritionists and physicians. In retrospect, early in the project we should have partnered more closely with our home care, extended care and palliative care partners including these groups in all aspectss of the project. Understanding what each service offers and how we Academic Center for Evidence Based Practice This abstract was presented at the 2013 Summer Institute on Evidence Based Practice. Theme: From Knowing to Doing To learn more visit: AR.uthscsa.edu ACE has published this as received and with permission from the author(s).

2 could best utilize these resources would have been invaluable from the start. there are varying degrees of service, that can be customized according to the needs of each patient. A closer partnership initially may have prompted more efficient utilization of services. Matching services to patient need could possibly increase acceptance of home care post discharge. Bibliography: Foust, J. Naylor, M., Bixby, B., Ratcliffe, S. (2012). Medication problems occurring at hospital discharge among older adults with heart failure. Journal of Geronological nursing, 5(1), Hansen, L. O., et al, (2011). Hospital discharge Documentation and risk of rehospitalisation. BMJ Qual Saf 2011; 20: Kaiser Health News. (2012). Medicare To Penalize 2,217 Hospitals For Excess Readmissions. August 13, Laugaland, K., Aase, K., & Barach, P., (2012). Interventions to improve patient safety in transitional care a review of the evidence. Work 41 (2012) DOI /WOR IOS Press Robert Wood Foundation: (2013). The Revolving Door: A Report on U.S. Hospital Readmissions February 2013.

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4 Looking at the Evidence: A Paradigm to Improve the Critical Thinking Skills of the Newly Trained Triage Nurse in the Emergency Department Janice M. Francischine, RN, MS, CPNP, CEN North Shore LIJ Health System Problem: Underdeveloped triage critical thinking skills can cause poor patient outcomes due to the inability to correctly assign triage categories for patients presenting in the Emergency Department. Evidence: During a recent quality review, it was noted that triage categories assigned by newly trained Emergency Department triage nurses often did not reflect the severity or lack of severity of the patients symptoms and or conditions. A thorough search of the literature using CINHAL and Medline revealed no evidence on the triage competencies of newly trained triage nurses.

5 Strategy: As a result of the evidence, a strategy was constructed to help assist and improve the critical thinking skills of the newly trained triage nurse in the Emergency Department. Practice Change: A paradigm was developed to improve critical thinking skills through chart review, remediation, and mentoring to improve the triage capabilities of newly trained Emergency Department triage nurses with less clinical experience. Evaluation: A cohort of newly trained ER triage nurses critical thinking skills who received the intervention was compared with newly trained ER triage nurses critical thinking skills who did not receive the intervention. Evaluation included the implementation of remediation which included the discussion of triage assignments, review of pathophysiology, and identification of the number of patient resources needed with reference to the ESI Version 4 Implementation Manual. Results: Significant improvement in appropriate triage assignments were revealed, which validates that this paradigm does aid, assist, and improve the critical thinking skills of the newly trained triage nurse in the Emergency Department. Recommendations: Underdeveloped triage critical thinking skills in newly trained triage nurses with less clinical experience can be improved through mentoring and outcome evaluations which ultimately improves patient care and clinical outcomes. Lessons Learned: With perseverance and patience, newly trained triage nurses can improve their critical thinking skills with the support and assistance of senior staff and use of this educational paradigm. Bibliography: Gilboy, N., Tanabe, P., Trever, D., Rosenau, A. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publiclation No Rockville, MD. Agency for Healthcare Research and Quality, McHugh,M., Tanabe, P., McClelland, M., Khare, R. More Patients are Triaged Using the Emergency Severity Index Then Any Other Triage Acuity System in the United States. Academic Emergency Medicine. 2012; 19(1): Singer, R., Infinity, A., Oppenheimer, C., West, C., Siegel, B. The Use of and Satisfaction with the Emergency Severity Index. Journal of Emergency Nursing. 2012; 38: