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Updated: Aug 31, 2025

A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
Improved 30-Day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE)
Beth Oliver1, Arlene Travis, Ellen Hughes
1Center for Nursing Research and Innovation (Dr Cohen), Mount Sinai Health System (Dr Oliver and Ms Hughes), New York City, New York; and The Mount Sinai Hospital, New York City, New York (Drs Travis and Cartwright and Mss Condrat and Ullman).
Background:
Heart failure readmissions are common, though some are preventable through evidence-based management.
Local Problem:
Despite outperforming national benchmarks for 30-day readmissions, compliance with an evidence-based institutional heart failure management pathway was inconsistent. The purpose of this project was to reduce 30-day heart failure readmission rates through an educational intervention and an electronic health record (EHR) redesign.
Methods:
The cardiac services nursing leadership team conducted an education and documentation needs assessment to identify knowledge gaps and practical barriers to effective utilization of evidence-based interventions for heart failure management.
Interventions:
This intervention included an Advanced Cardiovascular Education (ACE) Academy and an EHR workflow redesign for clinical and supportive nursing staff.
Results:
The 30-day heart failure readmission rates reduced immediately following the intervention, and rates continued to decrease over a 3-year follow-up.
Conclusions:
Even among hospitals outperforming national benchmarks, 30-day heart failure readmissions can be reduced and sustained with enhanced education and EHR redesign.
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