Impact of Nurse-Driven Discharge Education on 30-Day Readmission Rates in Heart Failure Patients

Introduction

Heart failure (HF) continues to be one of the most frequently cited diagnoses associated with 30-day hospital readmission among adult inpatients, with national readmission rates commonly reported between 20% and 25% (Centers for Medicare & Medicaid Services, 2023). Readmission within this early post-discharge window imposes substantial cost on healthcare systems and frequently reflects a failure of the discharge process to adequately prepare patients for the self-management demands of the post-hospitalization period, including daily weight monitoring, dietary sodium restriction, and timely recognition of early decompensation symptoms (Albert, 2021).

Discharge education is most commonly delivered as one component of a broader, multidisciplinary discharge process involving case managers, pharmacists, and physicians in addition to bedside nursing staff, with the specific responsibility for initiating and completing structured patient education often distributed across these roles or triggered by referral rather than being independently owned by the bedside nurse. This diffusion of responsibility can result in inconsistency, where the timing, depth, and completeness of discharge education a given patient receives depends substantially on whether referral processes are reliably activated during a particular admission, rather than on a standardized expectation applied uniformly to all patients meeting discharge criteria.

A nurse-driven model of care, in which bedside nurses are granted the authority and expectation to independently initiate defined clinical or educational protocols without requiring physician order or case-management referral, has demonstrated benefit in other clinical contexts, including nurse-driven protocols for catheter removal, mobility progression, and pain management (Newhouse et al., 2018). Extending this nurse-driven model specifically to discharge education for heart failure patients represents a logical extension of this evidence base, predicated on the assumption that bedside nurses, who possess the most continuous and proximate contact with the patient throughout hospitalization, are well positioned to independently assess discharge readiness and deliver individualized education without dependence on referral triggers that may be inconsistently activated. However, direct evidence isolating the effect of nurse-driven authority and workflow structure, as distinct from the content of discharge education itself, on readmission outcomes remains comparatively limited.

Given the persistent burden of heart failure readmission and the theoretical advantages of a nurse-driven discharge workflow structure, this study aimed to evaluate the effect of a nurse-driven discharge education intervention, in which bedside nurses independently initiated and completed structured discharge preparation without requiring referral, on 30-day all-cause readmission rates among adult patients hospitalized with heart failure, in comparison to standard discharge processes reliant on multidisciplinary referral.

Methods

This study employed a prospective, cluster-controlled design conducted across eight medical-surgical and cardiac telemetry units located within four acute care hospitals in the same regional health system, over an 11-month period. Units were assigned, at the site level, to either the nurse-driven discharge education arm or the standard discharge arm, with two units per hospital assigned to each condition to reduce the likelihood of systematic site-level confounding. Adult patients aged 18 years or older admitted with a primary diagnosis of heart failure and discharged to home were eligible for inclusion. Patients discharged to hospice or skilled nursing facilities, or with a length of stay under 24 hours, were excluded. A total of 398 patients were enrolled: 201 on nurse-driven discharge education units and 197 on standard discharge units.

On nurse-driven discharge education units, bedside nurses were granted standing authority, formalized through a hospital-approved nursing protocol, to independently initiate a structured discharge readiness pathway for any patient meeting heart failure diagnosis criteria, without requiring physician order or case-management referral to trigger the process. This pathway required completion of three core components:

1.A structured discharge readiness assessment, completed by the bedside nurse at least 24 hours prior to anticipated discharge, evaluating the patient’s demonstrated understanding of self-care requirements and identifying specific gaps requiring additional teaching prior to discharge.

2.An individualized, nurse-authored symptom-monitoring plan, specifying patient-specific weight thresholds, symptom triggers for contacting a healthcare provider, and a written medication schedule reflecting any regimen changes made during hospitalization.

3.A nurse-led medication reconciliation review conducted directly with the patient at the bedside prior to discharge, independent of the standard pharmacy reconciliation process, specifically to verify patient understanding of medication changes rather than solely verifying record accuracy.

On standard discharge units, discharge education continued to follow existing multidisciplinary workflows, in which structured education was typically delivered following case-management or physician referral, without a standing independent nursing protocol authorizing bedside nurses to initiate the process unprompted. The primary outcome was all-cause 30-day hospital readmission, obtained through the health system’s electronic health record and regional health information exchange. Readmitted patients were additionally interviewed using a brief structured questionnaire assessing perceived clarity of discharge instructions at the time of readmission. Chi-square tests compared readmission rates between arms, and multivariate logistic regression was used to adjust for age, ejection fraction category, and comorbidity burden. Statistical significance was set at p < .05, and analyses were conducted using SPSS version 29.

Results

Patient characteristics, including age, sex, ejection fraction category, and comorbidity burden, did not differ significantly between the nurse-driven discharge education arm and the standard discharge arm (all p > .05), supporting comparability between groups. Documentation review confirmed that the structured discharge readiness pathway was completed for 94.5% of eligible patients on nurse-driven units, compared to structured discharge education being documented for only 61.2% of eligible patients on standard units, reflecting the intended difference in workflow reliability between the two conditions.

The 30-day all-cause readmission rate was significantly lower on nurse-driven discharge education units compared to standard discharge units, at 15.4% (31/201) versus 25.9% (51/197) respectively (χ² = 7.51, p = .006). In the adjusted logistic regression model, care on a nurse-driven discharge education unit remained independently associated with significantly lower odds of 30-day readmission after adjusting for age, ejection fraction category, and comorbidity burden (adjusted odds ratio = 0.49, 95% CI 0.30–0.80, p = .004).

Among the 82 patients readmitted within 30 days across both arms, structured interview data revealed a marked difference in perceived discharge clarity. Readmitted patients from standard discharge units were significantly more likely to report unresolved uncertainty regarding their specific weight-gain threshold for contacting a provider (58% versus 26% among readmitted nurse-driven-unit patients) and regarding recent medication changes made during hospitalization (49% versus 19%). Subgroup analysis further indicated that the readmission benefit associated with nurse-driven discharge education was most pronounced among patients with a length of stay of four days or fewer, a group in which standard multidisciplinary referral processes may be least likely to be reliably activated prior to discharge, suggesting that the nurse-driven model’s independence from referral triggers may confer particular benefit during shorter admissions.

Discussion

The findings of this study demonstrate that restructuring discharge education around independent bedside nursing authority, rather than relying on multidisciplinary referral to trigger structured education, was associated with a significant reduction in 30-day readmissions among heart failure patients. The magnitude of readmission reduction observed is consistent with, and in some respects exceeds, findings reported in prior discharge education intervention research (Albert, 2021), and the marked difference in documented completion rates between study arms, 94.5% versus 61.2%, suggests that workflow reliability, not merely educational content, was a meaningful contributor to this effect.

The structured interview findings among readmitted patients provide further insight into the likely mechanism underlying this benefit. Readmitted patients from standard discharge units were substantially more likely to report specific, identifiable gaps in understanding, particularly regarding individualized weight-monitoring thresholds and medication changes, precisely the categories of information the nurse-driven pathway explicitly required bedside nurses to address through an individualized, nurse-authored plan. This pattern suggests that the nurse-driven model’s benefit derived not from providing fundamentally different educational content, but from more reliably ensuring that individualized, patient-specific information was actually delivered and verified prior to every eligible discharge, regardless of whether a referral had been generated.

The finding that the readmission benefit was most pronounced among patients with shorter lengths of stay carries a practical implication for hospitals implementing discharge education reform. Referral-dependent discharge workflows may be particularly vulnerable to failure during shorter admissions, where the time available for a referral to be generated, received, and acted upon by ancillary services is compressed. A nurse-driven model, in which the bedside nurse independently owns responsibility for initiating discharge preparation from early in the admission rather than awaiting referral, may therefore offer disproportionate benefit precisely in the shorter-stay population that referral-dependent systems are most likely to underserve. This observation aligns with the broader nurse-driven protocol literature, which has similarly identified workflow reliability, rather than clinical content alone, as a key mechanism through which nurse-driven models improve care consistency (Newhouse et al., 2018).

This study has several limitations. The cluster-controlled design, with assignment at the unit rather than individual patient level, introduces the possibility of residual unit-level confounding related to leadership, culture, or baseline nursing staffing that could not be fully addressed through statistical adjustment. The four-site, single regional health system setting may limit generalizability to hospitals with different nursing scope-of-practice policies or discharge workflow structures. Readmissions to outside facilities not captured through the regional health information exchange may have been missed, potentially underestimating the true readmission rate in both arms. Future research employing randomization at the patient level within units, and examining the specific components of the nurse-driven pathway most strongly associated with reduced readmission, would further strengthen this evidence base. Despite these limitations, the findings support restructuring heart failure discharge workflows to grant bedside nurses independent authority and expectation to initiate structured, individualized discharge education without dependence on referral, as a concrete strategy for improving the consistency of discharge preparation and reducing preventable early readmission.

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