In the 4East Med–Tele unit, reducing heart failure readmissions and improving care coordination has been a key interprofessional focus. The Heart Failure Committee, comprised of nurse champions Amy Miyagi, BSN, RN, Bryan Jackman, MSN, RN, 4East Manager, Maria Martin, BSN, RN together with the quality department and physician champion, meets regularly to review process measures and identify opportunities to improve patient outcomes.

Using the NCAL Inpatient Heart Failure Dashboard and evidence-based practice standards, the team noted inconsistent adherence with daily weights, intake and output documentation, and patient education. These gaps were linked to variation in patient management and potential readmissions.

To address this, the team launched a Heart Failure Education and Documentation Campaign, standardizing daily standing weights, reinforcing intake and output documentation every shift, and ensuring patient education completion prior to discharge. Flyers and reminders were developed by staff nurses and shared during morning huddles, staff meetings and posted on the unit to reinforce expectations.

Each discipline played a vital role:
• Nursing: Performed and documented daily weights, I&Os, and reinforced patient teaching.
• Physicians: Used standardized CHF order sets and reviewed fluid status daily.

Over the following six months, adherence to key process measures improved:
• Daily weight adherence increased
• I&O documentation improved
• Discharge summary completion rose by 21%
• Most importantly, 30-day all-cause readmissions decreased to zero, demonstrating sustained excellence in care coordination and patient education.

This initiative strengthened communication across disciplines and empowered bedside nurses to be active partners in reducing readmissions, ensuring that every patient with heart failure transitions safely from hospital to home.