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The intervention of providing discharge instructions, and adherence to follow up visits for patients who are discharged with a diagnosis of chronic heart failure are to prevent 30 day readmission for patients. The evidenced based practice in providing patient education prior to discharge is meant to reduce 30 day readmissions for these patients. Congestive heart failure (CHF) is the most common cause of hospitalization in the US for people older than 65 years of age. It has the highest 30-day re-hospitalization rate among medical and surgical conditions. A study that was published by PubMed, conducted a retrospective data collection that found that the intervention of providing discharge instructions prevented or lowered the amounts of readmission within 30 days for those patients with CHF. “As part of our study, we ensured that 58% of the enrolled patients had a follow-up appointment scheduled within two weeks of discharge compared to only 30% in 2017. Also, 56% of the enrolled patients kept their follow-up appointments compared to 37% in 2017. The 30-day readmission rate of CHF patients was reduced in half after the implementation of our project, with a 14% readmission rate for our study patients compared to 28% in 2017” (Nair et, al., 2020). So it can be concluded that patient education and measures to introduce post-discharge instructions and follow-up appointments adherence can lead to substantial reductions in the readmission rates of heart failure (HF) patients.




Implementation of evidence-based practice, derive from well-designated studies, is an essential factor in guiding clinical performance to improve quality outcomes, reduce cost, and re-create interventional processes (Melynk & Fineout-Overholt, 2019)

When I began as surgical unit manager, After reviewing policies and procedures, I felt the surgical timeout and block timeouts before surgery were overlooked due to time-consuming and less valuable. But is very important to provide high-quality and safe patient care to prevent wrong-site surgery. I changed the policy that time outboards must be completed and uploaded before each surgical procedure and placed time-out blocks in each OR room. When this change first started, many surgeons and staff were frustrated with the new change. Until a few weeks into using the boards and time-out process, it prevented wrong-site surgery. When the surgical team got to see the importance firsthand, they were thankful for the changes and appreciated that I kept pushing the significance. After that, they backed my updates and changes I made to better the evidence base standard of care.

One of the organizational changes I would use in my advanced nursing role is The Transtheoretical Model (TTM). (LaMorte, 2019) The model emphasizes intentional change; it operates in the thought that behavior is an ongoing characteristic. (LaMorte, 2019). It is a six-step process that concentrates on the stages of change to ensure a positive outcome and develop a structural framework. (LaMorte, 2019). The importance of this model is to enhance the overall healthcare patients receive.

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