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Discharge Planning for Cardiac Patients: Change Model

Every disease and health problem has its management and care plan. The Centers for Disease Control and Prevention (2016) reports that heart failure is observed in 5.5 million people with half of these cases ended in death within 3-5 years. In this paper, the problem of discharge planning from hospitals for patients who have congestive heart failure (CHF) will be discussed to explain how the ACE Star model can be used as a part of the evidence-based practice process.

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Change Model Overview

The ACE Star model is one of the most frequently used models in any evidence-based practice process. The main reason for nurses to use this model is the possibility to combine scientific knowledge, organizational skills, management, and change within the frames of one particular policy (Correa-de-Araujo, 2016). The ACE Star model as a part of the EBP process aims at maintaining knowledge through the prism of old and new concepts and supporting the idea of high-quality healthcare services that can be offered to clients.

The transformation of knowledge occurs in five main stages: discovery, evidence summary, translation and guidelines, practical integration, and the evaluation of outcomes (Correa-de-Araujo, 2016). The clinical scope of the evidence-based nursing practice helps to introduce the standards, identify the existing limitations, and improve the quality of services.

Define the Scope of the EBP

Discharge planning for CHF patients is the issue under consideration. The main problem of this study is the necessity to deal with readmissions among CHF patients. It is expected to clarify what healthcare workers can do to avoid heart-related complications, and how adult patients can avoid hospital readmission. About 20-25% of patients with heart failures are usually readmitted to hospitals within the next 30 days, and about 20-40% of them die within the next year (Riley & Masters, 2016). In the local work area, this problem is not as urgent as on a broader scale. Still, nurses try to do everything possible to avoid the growth of serious complications. Within 1-2 years, it is possible to evaluate the practice and check if the interventions are effective.


In addition to a leader of a research team, there is a need for several participants who have to perform their duties reasonably. It is enough to choose one charge nurse, two registered nurses, one hospital administrator, and one clinical educator. All team members have to cooperate to make sure that all information is properly shared and used.

Determine Responsibility of Team Members

A charge nurse is aware of what standards and material are offered to registered nurses. This person helps to define the difference between what is expected and what is obtained. Registered nurses are the main sources of information about patients, heart problems, readmissions, and the methods to monitor health. A hospital administrator plays an important role in this study due to the possibility to influence each member of a team and find the required information. Finally, a clinical educator has to be chosen. This person may cooperate either with nurses or patients and their families. An educator can research and define the problems in the area of discharge planning and use his/her knowledge to help other participants choose the most appropriate intervention.


The increase of readmissions among older patients with CHF turns out to be a serious public concern due to its hard-to-define complications that may lead to death. The studies developed in different parts of the world prove the possibility to prevent readmissions through controlling risk factors for heart failures (Centers for Disease Control and Prevention, 2016), early detection of an acute decompensation (Riley & Masters, 2016), or medication safety and patient education (Correa-de-Araujo, 2016). Special guidelines can strengthen this research.

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Many organizations offered guidelines on how to manage heart failure among patients. This EBP process is improved through the guidelines developed by the American Heart Association in terms of which patient-centered communication, symptom management, and lifelong learning are promoted. Clinical practice guidelines of the chosen facility have similar sections with the necessity to focus on the help that can be offered as a part of primary care and care during readmission.

Summarize the Evidence

The systematic review of articles helps to define several interventions to solve the current problem. Remote care for discharged patients is the solution the effectiveness of which has to be proved (Correa-de-Araujo, 2016). Heart problems cannot be managed within one specific guideline. Therefore, the recognition of all patients’ needs and demands is the main requirement (Centers for Disease Control and Prevention, 2016). Patient transitions between a hospital setting and home cannot be ignored, and nurses should make sure that improved communication, timely discharge, and education are properly offered to every patient (Riley & Masters, 2016). This combination of interventions is the practice for this study.

Develop Recommendations for Change Based on Evidence

The main recommendation for change includes an understanding of a variety of knowledge for healthcare workers and patients. It is not enough to teach nurses and promote communication with patients (Riley & Masters, 2016). The reduction of readmission rates depends on how well patients understand their tasks and take care of themselves.


Action Plan

To implement the pilot study, several steps within a certain timeline have to be developed:

Step Time Outcome
Investigation of readmission cases One week To learn the current state of affairs and define the scope of the problem locally
Communication with nurses and their work observation One month To identify the current methods of work with patients
Determination of weak aspects One week To analyze possible areas of improvement
Education of nurses and patients and remote care practice From one to five months To improve the participants’ level of knowledge and develop new skills
Results (comparison table) In one year To check if there are differences in readmission among CFH patients

Process, Outcomes Evaluation, and Reporting

It is expected to reduce the readmission rate by up to 50%. Patients should know how to succeed in hospital-home transitions. Families participate in CFH remote care. The results will be reported after the analysis of the statistical data obtained from observations and hospital reports.

Identify Next Steps

The next step of the study will be the implementation of the same techniques in other hospitals. Education, communication, and remote care should become an integral part of any discharge process. Patients should share their opinions and offer the areas of knowledge to be covered by nurses and clinical educators.

Disseminate Findings

Internally, the findings can be communicated through face-to-face discussions and lectures during which the recent achievements and numbers are introduced. Externally, participation in TED conferences can be a significant outcome. The main expectation is to share the obtained knowledge.

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In general, patient safety and readmission are the two important practices in healthcare settings. Many problems and organizational shortages prevent the improvement of care and promote the creation of new debates. Still, the promotion of remote care to reduce readmission rates among CFH patients through the ACE Start change model is the achievement that has to be recognized. Research, evidence, guidelines, integration, and evaluation of CHF patient care, hospital-home transition, and remote care is the plan that can help patients and hospitals.


Centers for Disease Control and Prevention. (2016). Heart failure fact sheet. Web.

Correa-de-Araujo, R. (2016). Evidence-based practice in the United States: Challenges, progress, and future directions. Health Care for Women International, 37(1), 2-22.

Riley, J. P., & Masters, J. (2016). Practical multidisciplinary approaches to heart failure management for improved patient outcome. European Heart Journal Supplements, 18(G), 43-52.

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