Other Titles
Optimizing Heart Failure Clinic Referrals Using a Heart Failure Readmission Risk Score [Title Slide]
Abstract
Background: Heart failure (HF) readmissions result in patients’ poor quality of life, depleted healthcare resources, reduced quality scores, and poor payor reimbursement, affecting healthcare systems’ financial stability. This is alleviated by referral to the HF Clinic. The project aims to compare HF Clinic referral rates after risk-assessing admitted HF patients with the European Collaboration on Acute Decompensated Heart Failure (ELAN-HF) risk tool to referral rates before the intervention. A goal is to utilize the ELAN-HF risk stratification tool to identify patients with the highest risk of readmission, refer them to the nurse-led HF Clinic, and provide self-care education and clinical monitoring to reduce HF readmissions at the project site.
Methods: Decompensated, 18 and older HF patients with an elevated NT pro-BNP (N-Terminal Pro-B-Type Natriuretic Peptide) value, on a cardiac stepdown unit. The Knowledge to Action translational science theory supported project implementation.
Results: Pre-intervention, 27 HF patients were referred to the HF clinic, with zero patients receiving a risk assessment. Post-intervention, 55 patients were referred to the HF Clinic. Nineteen patients were assessed with the ELAN-HF tool. Six scored high for readmission risk and were referred to the HF Clinic. Per inferential statistics, the intervention was not statistically significant, with p = .083.
Conclusion: The ELAN-HF risk assessment tool identified patients at high risk for HF readmission. The intervention did not statistically impact referral rates to the HF clinic. The risk assessment highlighted the importance of analyzing the NT-proBNP value before discharge and the relative change in the lab value throughout the admission. The analysis of this quantitative lab value reveals whether the patient’s HF status has improved mildly or significantly. The higher the ELAN-HF risk score, the higher the risk of readmission. Identifying patients at greatest risk for readmission provides clarity on which patients should receive the greatest clinical resources to avoid readmission. Tasking the nursing staff with the risk scoring augmented their understanding of HF, and enhanced clinical collaboration with the interdisciplinary team. The nursing staff significantly increased their knowledge of HF care resources available to patients following a HF admission.
Notes
References:
1. Kadoglou, N. P. E., Parissis, J., Karavidas, A., Kanonidis, I., & Trivella, M. (2022). Assessment of acute heart failure prognosis: The promising role of prognostic models and biomarkers. Heart Failure Reviews, 27(2), 655–663. https://doi.org/10.1007/s10741-021-10122-9
2. Savarese, G., Becher, P. M., Lund, L. H., Seferovic, P., Rosano, G. M., & Coats, A. J. (2023). Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovascular Research, 118(17), 3272–3287. https://doi.org/10.1093/cvr/cvac013
3. Shiraishi, Y., Kawana, M., Nakata, J., Sato, N., Fukuda, K., & Kohsaka, S. (2021). Time sensitive approach in the management of acute heart failure. ESC Heart Failure, 8(1), 204-221. https://doi.org/10.1002/ehf2.13139
4. Son, Y.-J., Choi, J., & Lee, H.-J. (2020). Effectiveness of nurse-led heart failure self-care education on health outcomes of heart failure patients: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(18), 6559-. https://doi.org/10.3390/ijerph17186559
5. Vinck T., Deneer R., Verstappen C., Kok, W., Salah K., Scharnhorst V. (2022). Validation of the ELAN-HF Score and self-care behaviour on the nurse-led heart failure clinic after admission for heart failure. BMC Nursing, 21(1), 1–158. https://doi.org/10.1186/s12912-022-00914-1
Sigma Membership
Phi Pi
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Other
Keywords:
Heart Failure, Readmission, Interprofessional Relations, Collaboration, Referral and Consultation
Recommended Citation
Borkosky, Marianne Rusin, "Optimizing Nurse-Led Heart Failure Clinic Referrals Using a Heart Failure Readmission Risk Score" (2026). International Nursing Research Congress (INRC). 52.
https://www.sigmarepository.org/inrc/2026/presentations_2026/52
Conference Name
37th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Toronto, Ontario, Canada
Conference Year
2026
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-07-24
Optimizing Nurse-Led Heart Failure Clinic Referrals Using a Heart Failure Readmission Risk Score
Toronto, Ontario, Canada
Background: Heart failure (HF) readmissions result in patients’ poor quality of life, depleted healthcare resources, reduced quality scores, and poor payor reimbursement, affecting healthcare systems’ financial stability. This is alleviated by referral to the HF Clinic. The project aims to compare HF Clinic referral rates after risk-assessing admitted HF patients with the European Collaboration on Acute Decompensated Heart Failure (ELAN-HF) risk tool to referral rates before the intervention. A goal is to utilize the ELAN-HF risk stratification tool to identify patients with the highest risk of readmission, refer them to the nurse-led HF Clinic, and provide self-care education and clinical monitoring to reduce HF readmissions at the project site.
Methods: Decompensated, 18 and older HF patients with an elevated NT pro-BNP (N-Terminal Pro-B-Type Natriuretic Peptide) value, on a cardiac stepdown unit. The Knowledge to Action translational science theory supported project implementation.
Results: Pre-intervention, 27 HF patients were referred to the HF clinic, with zero patients receiving a risk assessment. Post-intervention, 55 patients were referred to the HF Clinic. Nineteen patients were assessed with the ELAN-HF tool. Six scored high for readmission risk and were referred to the HF Clinic. Per inferential statistics, the intervention was not statistically significant, with p = .083.
Conclusion: The ELAN-HF risk assessment tool identified patients at high risk for HF readmission. The intervention did not statistically impact referral rates to the HF clinic. The risk assessment highlighted the importance of analyzing the NT-proBNP value before discharge and the relative change in the lab value throughout the admission. The analysis of this quantitative lab value reveals whether the patient’s HF status has improved mildly or significantly. The higher the ELAN-HF risk score, the higher the risk of readmission. Identifying patients at greatest risk for readmission provides clarity on which patients should receive the greatest clinical resources to avoid readmission. Tasking the nursing staff with the risk scoring augmented their understanding of HF, and enhanced clinical collaboration with the interdisciplinary team. The nursing staff significantly increased their knowledge of HF care resources available to patients following a HF admission.
Description
HF readmissions are a key performance indicator that institutions find challenging and a global healthcare quality and financial concern. HF patients are not usually assessed for HF readmission risk at discharge. This creates an intriguing opportunity to evaluate patients for a HF clinic referral based on quantitative HF lab values. A referral to a nurse-led HF clinic for increased clinical monitoring, education on self-care and disease management, can reduce HF readmissions.