Improving 30-Day Readmission Rate in Adult Heart Failure Patients

Jewell Doss

Background: Heart failure is a leading cause of hospitalization and 30-day readmissions among adults in the United States, resulting in significant clinical and financial burden. Despite established guideline-directed medical therapy and evidence-based transitional care strategies, gaps persist in provider prescribing practices, patient self-management, and standardized post-discharge risk assessment, particularly in rural and resource-limited settings. Purpose: The purpose of this quality improvement project was to reduce 30-day hospital readmissions among adult patients with heart failure through implementation of a multifaceted, evidence-based interventions on a medical-surgical unit and affiliated primary care clinic. Methods: This quality improvement project was guided by the Iowa Model for Evidence-Based Practice and implemented in a mid-sized, nonprofit hospital in the north-central United States. Three interventions were introduced: provider education to improve initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors during hospitalization, patient engagement in daily weight monitoring using a red weight log sheet, and use of a standardized heart failure readmission risk assessment tool during post-discharge follow-up. Data collection included pre- and post-intervention provider surveys, patient adherence tracking, risk assessment completion rates, and monthly 30-day readmission counts. Descriptive statistics and run chart analysis were used to evaluate outcomes. Findings: Provider self-reported willingness to initiate or adjust SGLT2 inhibitor therapy improved following targeted education, with an increase in “excellent” ratings and elimination of “fair” responses. Patient adherence to daily weight monitoring improved, increasing from 25% during early implementation to 75% in the final two months. The heart failure readmission risk assessment tool achieved 100% completion during the active implementation period. Monthly 30-day readmissions fluctuated, with lower rates observed toward the end of the project period. Discussion: Findings suggest that combining provider education, patient-centered self-monitoring tools, and structured readmission risk stratification is feasible and may strengthen transitional care processes for patients with heart failure. While limited by small sample size and short implementation duration, the project supports the value of low-cost, scalable interventions to enhance guideline adherence, patient engagement, and early identification of high-risk patients. Continued implementation and longer-term evaluation are recommended to assess sustainability and impact on readmission outcomes.

Improving 30-Day Readmission Rate in Adult Heart Failure Patients

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