Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2020


Doctor of Nursing Practice (DNP)

Primary Advisor

Dr. Pearl Zhou, PhD, RN; Dr. Mary Jane Neri, DNP, MSN, RN, CSSM, CNOR


Heart failure, readmission, multidisciplinary, rural


Background: Despite the national efforts to decrease 30-days hospital readmissions, readmission remains a challenge for healthcare organizations across the continuum of care. The aim of this quality improve project was to develop and implement a multidisciplinary team approach to provide education to patients hospitalized with congestive heart failure (CHF) to improve 30-day hospital readmissions.

Method: This project was conducted in a critical access hospital in Northeast Washington. Using a pre-post design, we evaluated the 30-day readmission before and after implementing the multidisciplinary education program for patients hospitalized with CHF. The education focused on disease management, discharge education, pharmacy consult and medication education, and follow up discharge call within 14 days post discharge. Data were collected from chart reviews.

Results:There were 42 patients in the pretest and 52 in the posttest. Patients in the posttest were significantly older (75.77 years) than those in the pretest (66.81 years), p

Conclusion: This project provided a comprehensive educational approach to decrease 30-days readmission. Although the multidisciplinary approach showed improvement in practice standardization, it was not possible to perform a statistical test due to low incident. Continue the current process and extend data collection should be done to determine the impact of the intervention.

Open Access


Included in

Nursing Commons



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