Coordinated follow-up program reduces readmissions, deaths for heart attack patients

A systematic approach to transitioning heart attack patients from the hospital to outpatient care helped the Sanger Heart & Vascular Institute in Charlotte, North Carolina, drop its 30-day readmission and death rates while increasing the likelihood of patients making and keeping follow-up appointments.

Results of the effort were presented Feb. 14 at the American College of Cardiology’s Cardiovascular Summit in Orlando, Florida.

The program involved a nurse navigator meeting with each patient prior to discharge, calling them within a day or two of discharge and then every two to four weeks for three months. During the pre-discharge meeting, the nurses ensured their patients scheduled a follow-up appointment, had the appropriate medications and understood their treatments. The additional phone calls were to reinforce these messages and address any other questions or concerns that patients developed.

“In the past, if something happened that caused concern to the patient, we’d tell them to call the office, where they often didn’t know anyone,” lead researcher William E. Downey, MD, Sanger’s medical director of interventional cardiology, said in a press release. “Now, patients have a nurse navigator they know who gives them their cell number and can provide reassurance or a sound plan for taking action if needed. It’s an important bridge until the patient develops a firm relationship with their new cardiologist’s office.”

The researchers studied data from 560 patients who were treated for a heart attack in the year before the program began in July 2017, along with outcomes of 421 patients in the year after the program was implemented. Prior to the program, a discharging nurse would provide discharge education and usually offer a referral to cardiac rehabilitation, which was responsible for providing additional education.

After the program started, the 30-day readmission rate dropped from 6.3 percent to 3.7 percent, the 30-day death rate dipped from 5.75 percent to 4.57 percent and patients were more likely to schedule follow-up appointments prior to discharge (96 percent versus 78 percent).

There were also small increases in the proportions of patients receiving guideline-based care (83.3 percent to 85.1 percent) and being referred to cardiac rehab (85.7 percent to 88.6 percent).

“This study shows that nurse navigators are an integral part of reducing heart attack readmission and mortality,” said Amber Furr, BSN, RN, performance improvement coordinator at Sanger. “We’re not where we want to be yet with cardiac rehab referrals or guideline-driven care, but we have seen an improvement.”