Heart failure (HF) is one of the most common and costly conditions for hospital readmissions in the United States (Conway, 2015). Cardiac rehabilitation (CR) programs are effective in decreasing hospital readmission rates (Koukoui, Desmoulin, Lairy, Bleinc, Boursiquot, Galinier, & Koukoui, 2015). Medicare has established new requirements for qualification into a CR program; thus, patients are at risk for readmission in the six-weeks post discharge. To reduce HF hospital readmissions and to increase enrollment into the HF program, an infrastructure was implemented beginning in January 2016. This quality improvement project employed a patient chart audit reviewing overall hospital readmission rates for HF at a large hospital in Arizona.

A comparison of readmission rates was made between the 6 months prior to, and the 6-months after the expanded utilization of the HF program. An independent-samples t test was calculated comparing the mean score of the readmission rates before and after a HF CR intervention. No significant difference was found (t(358) = .721, p > .05). The mean of the group before the intervention (m =.15, sd = .36) was not significantly different from mean in the intervention group (m = .13, sd = .33). Implications for practice cannot completely be concluded from this project findings. Continued studies focusing on the enrollment, attendance, and completion of the HF CR program could assist in determining the benefits of referring all patients with the diagnosis of HF to the HF CR program.

Emergency department (ED) overcrowding is expected to increase at a rate of 1.9% yearly, leading to the inability to provide efficient and timely care, causing preventable medical errors and delays in time sensitive care. The Agency for Healthcare Research and Quality estimates that 21-33% of all ED visits are non-emergent and increased age correlates with increased use of Pre-hospital EMS systems and emergency rooms. This study aimed to determine if an advance practice nurse (APN) in an older adult pre-hospital setting could reduce the use of 911 for non-urgent calls and transports, using the para-medicine model of care. Available evidence demonstrated a decrease in non-urgent transports with potential for significant savings to the healthcare system.

This study was conducted in a community where 86.3% of residents are over the age of 65. The local fire department employed a full time APN who evaluated patients identified by EMS crews as at risk for repeat use of the 911 system. Following a 911 call and a referral by medics, the APN contacted patients to arrange a home visit. The purpose served to evaluate current health status, risks, and gaps in care. Interventions included assistance reducing safety concerns, assistance with coordination of care, and working with patient primary care providers to meet patient needs. Data collection included patient age, gender, number of 911 calls 30 days prior and 30 days post intervention, number of ambulance transports following intervention and PEI score after the initial APN visit.

Six patients (32%) accepted the intervention and 13 or (68%) refused the intervention, with a mean age of 86 years of age. Wilcoxin signed rank test indicates the number of pre-intervention 911 calls was statistically significantly higher than the number of post-intervention 911 calls. Z= -2.23, Asymp. Sig. (2 tailed) = 0.03. A Fisher’s exact test and Pearson’s Chai squared test did not demonstrate a statistical significance in the number of ambulance transports, which could be attributed to the low participation rate in the intervention (n=6). These results indicate that an APN in the pre-hospital setting can have an impact on use of 911 calls for non-urgent problems and. Furthermore, the ability to assist with care coordination and advocate for available services within the circle of the medical home closes gaps in care that are currently left unfilled.