Capella FPX 4025 Assessment 3

Capella FPX 4025 Assessment 3

Student Name

Capella University

NURS-FPX4025 Research and Evidence-Based Decision Making

Prof. Name:

Date

Introduction

Acute Heart Failure (AHF) is a serious condition. It can cause trouble breathing, swelling, and feeling very tired. Many patients with AHF go back to the hospital within 30 days after they leave (Njoroge & Teerlink, 2021). This assessment aims to explain that special teaching and follow-up care after hospital discharge can help. When patients learn about their illness and get checked on later, they are less likely to return to the hospital. This support can also help them live longer and feel better. 

Outcomes, Risks, and Complications

AHF is a serious and potentially life-threatening condition. It occurs when the heart suddenly becomes unable to pump blood effectively, leading to poor circulation and fluid buildup in the body. People with AHF usually have symptoms, for instance, shortness of breath, tiredness, and swelling in the legs, all of which can greatly affect their daily lives and overall well-being. This condition is linked to high rates of illness, frequent hospital visits, and a risk of death, within the first month after leaving the hospital (Njoroge & Teerlink, 2021).

 The chances of recovery improve when AHF is recognized early, treated early, and managed using well-established medical guidelines. AHF can lead to several serious health problems, for example, fluid buildup in the lungs (pulmonary edema), irregular heart rhythms (arrhythmias), poor kidney function, and cardiogenic shock. These complications tend to affect certain groups of people more severely. Older adults, individuals with lower incomes, and racial or ethnic minorities often face greater challenges in receiving timely and fair healthcare.

Capella FPX 4025 Assessment 3

For instance, African American patients are more likely to be hospitalized for heart failure and often experience worse health outcomes. As of 2024, the heart failure death rate is higher in Black individuals (41.4 per 100,000) than in Whites (33.1 per 100,000), and nearly 50% of hospitalizations for ages 18–45 are among Black patients (Islam et al., 2025). This difference is caused by a mix of inherited traits, difficulties in getting access to specialized medical care, and larger, long-standing problems within the healthcare system that affect certain groups unfairly. 

Health disparities play a role in how well patients with AHF recover. For example, individuals living in underserved areas struggle with limited access to healthcare, challenges in getting their medications, and low levels of health literacy. These barriers lead to delays in receiving care and difficulty managing their condition, which increases the risk of hospital readmissions and even death (Morris et al., 2022). To improve recovery outcomes, it is essential to address the social factors, for example, implementing community-based programs and culturally sensitive health education that influence health. When nurses and other healthcare providers recognize these challenges, they are better able to develop care plans that are personalized and effective, promoting fairness and improving care for patients with AHF.  

PICO(T) Research Question

A research question was developed using the PICO(T) framework to address the issue of frequent hospital readmissions among patients diagnosed with AHF: In adult patients diagnosed with AHF (P), how does participation in a structured heart failure discharge education and follow-up program (I), compared to standard discharge procedures (C), affect 30-day hospital readmission rates (O) over a period of one month (T)?

Breakdown of the PICO(T) Criteria

• Population (P): The population includes adult patients diagnosed with AHF. These patients are at high risk of being readmitted to the hospital shortly after discharge. Focusing on this group helps address a well-known and costly issue in healthcare.
• Intervention (I): The intervention is participation in a structured heart failure discharge education and follow-up program. This program provides patients with individualized education about managing their condition, medication review, and scheduled follow-up appointments to monitor their progress and prevent complications.
• Comparison (C): The comparison is standard discharge procedures, which often do not include personalized education or follow-up care. These procedures may simply involve general instructions and limited patient support after leaving the hospital.
• Outcome (O): The outcome measured is the 30-day hospital readmission rate. This is a key indicator of how well heart failure patients are managed after discharge. Lower readmission rates often reflect better patient understanding and support.
• Time (T): The time frame is one month (30 days). This period is commonly used to assess early readmissions and the effectiveness of discharge interventions in heart failure care.

Using a PICO(T) question is a helpful and structured way to guide a literature review when looking for ways to improve care for patients with AHF (Gosak et al., 2024). This approach allows healthcare professionals to focus on research that examines specific methods to reduce hospital readmissions, which is a serious concern in both clinical care and health policy. By using this framework, nurses can easily find and apply effective strategies that not only improve patient health outcomes but also help lessen the burden on the healthcare system. 

Literature Search Description

A focused literature search was conducted to find evidence supporting the PICO(T) question related to reducing 30-day hospital readmissions in adult patients with AHF. The databases used included CINAHL, PubMed, and Google Scholar, all known for their relevance to healthcare research. Keywords used in various combinations with Boolean operators (AND, OR) included: “acute heart failure,” “30-day readmission,” “structured discharge education,” “follow-up care,” “multidisciplinary intervention,” and “nurse-led discharge program.” These terms helped refine the search and return studies that were directly aligned with the intervention and outcomes of interest. To ensure credibility, articles were selected based on the CRAAP criteria.

The CRAAP criteria include Currency, Relevance, Authority, Accuracy, and Purpose (Nakayama et al., 2022). Only peer-reviewed studies published within the last five years in the renowned journals were included to maintain currency. The search process was refined by limiting results to English-language articles, studies on adult populations, and those focused specifically on discharge education and follow-up care. These filters helped exclude irrelevant results and ensured that the final selection of studies provided strong, applicable evidence for the proposed intervention.

Relevant Articles

Three key scholarly articles provide strong evidence supporting the use of structured discharge education and follow-up programs to reduce 30-day hospital readmissions in patients with AHF. The first study by Rizzuto, Charles, and Knobf (2022) evaluated a multidisciplinary heart failure pilot program that included patient education, early follow-up calls (within 48–72 hours), and cardiology visits within a week of discharge. Before the program, the facility had a 28.6% readmission rate, higher than national and state averages. After implementation with 47 patients, the readmission rate dropped by 16.6%. This study is highly credible, published in Critical Care Nurse, a peer-reviewed journal, and used an evidence-based, team-care model. It is directly relevant to the PICO(T) question and AHF as it measures how structured discharge processes affect readmissions.

The second article by Davidge et al. (2023) explored clinical factors predicting heart failure readmissions in 5,029 patients. It found that 33% were readmitted and 12% died within 100 days. Risk factors included older age, longer hospital stays, kidney issues, and high NT-proBNP levels. Protective factors included being female and having higher blood pressure. Published in the International Journal of Cardiology Cardiovascular Risk and Prevention, this large, methodologically sound study is credible and helps identify which patients benefit most from enhanced discharge support, adding depth to the population and risk considerations in the PICO(T) question. This article is directly relevant to the PICO(T) question and AHF by highlighting clinical predictors of readmissions in adults with AHF. The study supports the need for structured discharge education and follow-up to reduce readmission rates.

Lastly, Wong et al. (2021) conducted a meta-analysis of 12 RCTs with 150,840 patients, reviewing 15 nurse-led interventions. This study shows that nurse-led education and follow-up interventions, though modest in effect, are as effective in reducing 30-day readmissions as more complex approaches, supporting structured discharge programs in AHF care. The article is credible, peer-reviewed, and published in the International Journal of Nursing Studies, reinforcing the relevance of nursing interventions in structured discharge programs. This article is directly relevant to the PICO(T) question and AHF by demonstrating that nurse-led education and follow-up interventions can effectively reduce 30-day readmissions, supporting the implementation of structured discharge programs for adults with AHF.

Analysis of Evidence

The evidence from all three articles supports the effectiveness of structured discharge education and follow-up in reducing 30-day readmissions in adult patients with AHF. Rizzuto et al. demonstrated a notable 16.6% drop in readmission rates after implementing a targeted education and follow-up program. Davidge et al. emphasized the importance of identifying high-risk patients using clinical indicators, which supports tailoring follow-up efforts to those most vulnerable. Wong et al.’s meta-analysis showed that even simple nurse-led interventions can reduce readmissions, suggesting that these programs do not need to be overly complex to be effective.

This analysis assumes that the patient populations in these studies reflect typical adult AHF demographics and that the discharge interventions are delivered as intended. Another assumption is that patients adhere to the education and follow-up provided. The studies highlight that when patients are educated on managing their condition and are monitored shortly after discharge, outcomes improve. This aligns with the PICO(T) question’s aim of comparing structured programs with standard discharge processes and confirms that structured interventions can reduce readmissions effectively, improving both patient care and healthcare resource use. 

Conclusion

Patients with AHF often return to the hospital soon after going home. This can be scary and hard for them and their families. Giving patients clear teaching and checking on them after discharge helps keep them healthier. It also lowers the chances of going back to the hospital. Simple care and support can make a big difference in their lives.

References

Davidge, J., Halling, A., Ashfaq, A., Etminani, K., & Agvall, B. (2023). Clinical characteristics at hospital discharge that predict cardiovascular readmission within 100 days in heart failure patients – An observational study. International Journal of Cardiology Cardiovascular Risk and Prevention, 16, 200176. https://doi.org/10.1016/j.ijcrp.2023.200176 

Gosak, L., Štiglic, G., Pruinelli, L., & Vrbnjak, D. (2024). PICOT questions and search strategies formulation: A novel approach using artificial intelligence automation. Journal of Nursing Scholarship, 57(1). https://doi.org/10.1111/jnu.13036 

Islam, K. N., Islam, R. K., Nguyen, I., Magherahabed, Y., Pirzadah, H., & Rashid, M. B. (2025). Heart failure in black populations: Epidemiology, pathophysiology, and treatment disparities. Journal of Racial and Ethnic Health Disparities. https://doi.org/10.1007/s40615-025-02371-3 

Morris, A., Shah, K. S., Enciso, J. S., Hsich, E., Ibrahim, N. E., Page, R., & Yancy, C. (2022). HFSA position statement the impact of healthcare disparities on patients with heart failure. Journal of Cardiac Failure, 28(7). https://doi.org/10.1016/j.cardfail.2022.04.008 

Nakayama, K., Yonekura, Y., Danya, H., & Hagiwara, K. (2022). Associations between health literacy and information-evaluation and decision-making skills in Japanese adults. BMC Public Health, 22(1). https://doi.org/10.1186/s12889-022-13892-5 

Capella FPX 4025 Assessment 3

Njoroge, J. N., & Teerlink, J. R. (2021). Pathophysiology and therapeutic approaches to acute decompensated heart failure. Circulation Research, 128(10), 1468–1486. https://doi.org/10.1161/circresaha.121.318186 

Rizzuto, N., Charles, G., & Knobf, M. T. (2022). Decreasing 30-day readmission rates in patients with heart failure. Critical Care Nurse, 42(4), 13–19. https://doi.org/10.4037/ccn2022417 

Wong, C. H., Cheung, W. K., Zhong, C. C., Yeoh, E., Hung, C. T., Yip, B. H., Wong, E. L., Wong, S. Y., & Chung, V. C. (2021). Effectiveness of nurse-led peri-discharge interventions for reducing 30-day hospital readmissions: Network meta-analysis. International Journal of Nursing Studies, 117, 103904. https://doi.org/10.1016/j.ijnurstu.2021.103904