Standardized Telephone Follow-Up Calls for New Ventricular Assist Device Patients

Abstract

Problem & Purpose: The transition from hospital to home is a vulnerable period that poses significant challenges for complex patient populations such as those with ventricular assist devices (VADs). At the organization of interest, approximately 40% of VAD patients were readmitted within 30 days following their implant hospitalization which exceeded the national readmission rate. Many readmissions are preventable if effective discharge planning and timely follow-up occurs. The purpose of this project was to develop and implement a standardized telephone follow-up (TFU) script based on recommendations from the American Heart Association (AHA) and the Agency for Healthcare Research and Quality (AHRQ) to ensure new VAD patients were receiving discharge follow-up calls that addressed their unique post-discharge needs. Methods: The TFU script included questions about symptoms of heart failure, device alarms, follow-up appointments, medications, home health care, and dressing supplies and contained instructions for the caller based on patient responses. Unit nursing staff were educated on the use of the script and asked to make calls between 48-72 hours after discharge. Weekly discussions were held to facilitate the change in practice. The project tracked compliance with the TFU script and descriptive data were analyzed to measure the impact of the standardized call. Results: Over the 12-week implementation period, 7 of 7 eligible patients received a follow-up call for a 100% compliance rate. The overall script completion rate was 96%. The average time of call after discharge was 91 hours. Two patients (33%) did not have follow-up appointments and were transferred to the scheduling line. One patient (17%) did not receive medications on discharge, and five patients (83%) required additional transitional care coordination communicated to the VAD coordinator or heart failure nurse practitioner. An 8th patient was readmitted within 24 hours of discharge and could not receive a call. Conclusion: The use of a standardized TFU script can be successfully implemented by RN staff to help identify critical post-discharge needs and ensure compliance with recommended timely follow-up. Follow-up calls should address the specific needs of complex patient populations to facilitate successful transitions of care and reduce preventable readmissions.