Date of Award

January 2021

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

Mary Ann Camilleri


Sepsis, the leading cause of hospital readmissions in the United States, accounts for $23.7 billion of aggregate costs. The Medicare Hospital Readmissions Reduction Program (HRRP) requires hospitals to provide efficient patient discharge coordination to prevent readmissions or risk financial penalties. Although a substantial value capture opportunity exists to reduce avoidable readmissions, a significant gap exists in sepsis-specific discharge interventions. The purpose of this quality improvement project was to design and evaluate an evidence-based framework for reducing sepsis readmissions in the acute care setting with national impact. The novel, multidisciplinary framework developed here integrated literature on: (1) Sepsis Nurse-Navigator driven discharge interventions; (2) Patient awareness using an expert-validated sepsis education tool; and (3) Patient-Nurse collaboration using telehealth or telephonic follow-up at critical time points. Seventy-five community hospital patients with qualifying CMS (2019) Diagnosis Related Group (DRG) 870, 871, and 872 discharging to home or an assisted living facility participated for a total of 6 months. Comparative analysis included review of 30-day readmissions pre-and post-program. Patient and nurse satisfaction as indicators of sustainability or opportunities for improvement were examined. The reduction in readmission rate after program implementation was statistically and clinically significant. Observed readmission rate fell to 17.2% after implementation of the framework (Z=37.36, p < .001) vs. the 44.2% baseline rate. Intervention resulted in a large effect size of 27.0% (95% CI=25.2%, 28.0%). National outcomes of this Healthcare Leadership DNP project determine scalability across a 21-state health system, inform evidence-based discharge interventions, and contribute to best practices for sepsis readmission reduction nationally.


This is an Open Access Thesis.

Open Access

This Article is Open Access