Utilizing a Nurse Discharge Navigator to Reduce Readmissions for Hospitalized Patients With Sepsis: A Quality Improvement Feasibility Study.

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.