Nurse-Driven Zone-Based Heart Failure Protocol in Skilled Nursing Facilities: A Retrospective Cohort Study
Laura Cline
ABSTRACT
Background: Heart failure (HF) remains a leading cause of morbidity, mortality, and healthcare utilization among older adults, with skilled nursing facilities (SNFs) experiencing disproportionately high 30-day readmission rates owing to multimorbidity, cognitive impairment, and limited specialty access. Nursedriven zone-based protocols provide an opportunity to standardize HF management and improve early symptom recognition in post-acute care settings.
Objective: To evaluate the effect of a nurse-driven, zone-based HF protocol on 30-day rehospitalization rates and demonstrate the feasibility of implementing standardized, evidence-based HF management within the SNF environment using a retrospective cohort design.
Methods: This retrospective cohort study compared residents with documented HF hospitalizations during the 12-month pre-implementation period (2023) and 12-month post-implementation period (2024). The primary outcome was the 30-day readmission rate, calculated as the number of readmissions within 30 days of hospital discharge divided by the total number of hospitalizations. Secondary analyses included assessment of absolute and relative risk reductions with 95% confidence intervals (CI). Descriptive comparisons and effect size calculations were performed using prespecified statistical approaches.
Results: Pre-intervention analysis encompassed 907 hospitalizations, with 653 readmissions (72.0% readmission rate). Following the protocol implementation, 567 hospitalizations resulted in 295 readmissions (52.0% readmission rate). This represented an absolute reduction of 20 percentage points and a 27.8% relative reduction in readmission risk (RR=0.72; 95% CI: 0.67–0.78). The number of patients required to prevent one readmission was 5. Protocol fidelity metrics
demonstrated 89% adherence to zone-based assessments and 94% completion of mandatory HF specific variables during the implementation period.
