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Updated: Sep 14, 2025
A Data-Driven Approach to Quantifying Immune States in Sepsis
Published on: February 7, 2025
Utilizing a Nurse Discharge Navigator to Reduce Readmissions for Hospitalized Patients With Sepsis: A Quality
Marta Pruitt1,2,3,4, Abby Matusik1,2,3,4, Neelam Patel1,2,3,4
1Marta Pruitt, DNP, FNP-BC , is a nurse with 8 years of experience in adult medicine. Her current work lies in patient flow, capacity, throughput, and readmissions. She is a recent graduate of the Doctor of Nursing Practice program at Duke University. Marta will serve as the Corresponding and Reprint Author for this work.
Purpose/Objectives:
The purpose of this project was to evaluate the impact of a nurse discharge navigator implementing an education and structured outpatient follow-up program on reducing 30-day readmissions for adult patients with sepsis.
Primary Practice Setting:
This project was implemented at an 847-bed academic hospital in the southeastern United States.
Findings/Conclusions:
Patient capture in the study was poor, driven by high rates of cancer diagnoses, comfort-directed care, and frequent discharges to postacute care. Readmission rates for patients receiving the full intervention ( n = 16) were 25% ( n = 4). Overall readmission rates for patients with sepsis in 2024 were 13.3% ( n = 61). The outcomes of this project were influenced by the advanced comorbidities of the participants.
Implications For Case Management Practice:
Case management of patients with sepsis should be comprehensive. Caregivers should be involved early to initiate education on the disease process, have clear communication with the follow-up team, and involve close, structured follow-up that can be adapted to the postacute care setting. One promising area for improvement of this intervention would be the inclusion of a Hospital at Home program as a transition program to the transition clinic.
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