Graduation Semester and Year
Spring 2026
Language
English
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Michelle Hampton, PhD, NEA-BC, RN
Second Advisor
Kirsten Drake, DNP, RN, NEA-BC, ONC
Abstract
Background: Heart failure (HF) remains a major contributor to 30-day hospital readmissions, placing strain on patients, healthcare systems, and reimbursement structures tied to quality metrics. Inconsistent discharge practices and gaps in transitional care coordination increase the likelihood of preventable rehospitalizations.
Purpose: This project examined whether implementing a standardized, nurse-driven discharge bundle would improve transitional care outcomes and decrease 30-day readmissions among adults hospitalized with HF.
Methods: A practice-based quality improvement initiative was conducted in a 465-bed regional hospital over a 8-week period. Using iterative Plan-Do-Study-Act cycles, a structured discharge bundle was introduced for eligible HF patients discharged from medical-surgical and telemetry units. Bundle components included scheduling follow-up appointments prior to discharge, coordinating cardiac rehabilitation referrals, reinforcing medication adherence, providing smoking cessation resources when indicated, and delivering individualized education using teach-back strategies. Data from 122 patients were obtained through electronic health record review and 24-hour post-discharge follow-up calls. Outcomes were summarized using descriptive statistics and trend analysis. A sample of cases was independently reviewed to confirm data accuracy.
Results: Following implementation, improvements were observed in follow-up appointment attendance, referral completion, documentation of medication adherence, and overall compliance with the discharge bundle. Readmission trends demonstrated improvement compared to pre-implementation performance.
Conclusions: Standardizing nurse-led discharge workflows strengthens care transition processes and shows promise in reducing early rehospitalizations among HF patients. Structured discharge coordination represents a feasible and sustainable strategy to improve quality outcomes in acute care settings.
Keywords
Heart Failure Readmissions, Readmissions, Heart Failure, Decrease Heart Failure Readmissions
Disciplines
Cardiovascular Diseases | Quality Improvement
License
This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
Recommended Citation
Hudson, Carolyn, "A Structured Discharge Bundle to Reduce Heart Failure Readmissions" (2026). Doctor of Nursing Practice (DNP) Scholarly Projects. 117.
https://mavmatrix.uta.edu/nursing_dnpprojects/117