Background: Elderly inpatients are frequently admitted for pneumonia, urinary tract infections (UTIs), and cardiac diseases, leading to high readmission rates, increased healthcare costs, and progressive functional decline. Inadequate discharge planning and limited application of nurse-led models contribute to these challenges. Developing structured, nurse-led interventions is essential to enhance care quality and reduce preventable readmissions in this population.
Objective: To evaluate the effectiveness of nurse-led interventions in reducing readmission rates and improving care quality among elderly inpatients diagnosed with pneumonia, UTIs, and cardiac conditions.
Methods: A quasi-experimental pre–post design was conducted in the internal medicine ward of a regional hospital. The study population had a mean age of 85 years. Interventions included: (1) early risk screening at admission (nutrition, functional status, infection), (2) disease-specific care pathways and education, (3) structured discharge planning with referral follow-up, and (4) family-involved care training. Outcomes assessed were 30-day readmission rates, fall incidents, nutritional status, and nurse satisfaction. Data were collected from hospital records and national health insurance databases. Statistical analyses were performed to test differences before and after the intervention, with significance set at p<0.05. Results: Following implementation, 30-day readmission rates decreased significantly: from 18.5% to 9.2% for pneumonia, 14.7% to 6.3% for UTIs, and 21.1% to 11.4% for cardiac conditions (p < 0.05). Fall incidents were reduced by 36%. Nutritional status improved (MNA score increased from 17.8 to 22.4, p < 0.01), and nurse satisfaction rose from 3.6 to 4.5 on a five-point Likert scale. Conclusion: Nurse-led integrated interventions demonstrated effectiveness in improving care quality and reducing readmissions among elderly inpatients. This model offers a sustainable, nursing-centered approach to geriatric care and aligns with global priorities for aging populations.

Authors:
Ying Hua Cheh, Taipei City Hospital, Zhongxiao Branch, Taiwan
Ting Chih Ko, Taipei City Hospital, Zhongxiao Branch, Taiwan
Hsiao Chieh Hsu, Taipei City Hospital, Zhongxiao Branch, Taiwan
Shu-Feng Huang, Taipei City Hospital, Zhongxiao Branch, Taiwan
Chih-Ni Liao, Taipei City Hospital, Zhongxiao Branch, Taiwan

About the Presenter(s)
CHEH YING HUA is a senior clinical nurse specializing in internal medicine patient care. She currently serves as an experienced frontline practitioner responsible for comprehensive assessment, chronic disease management, and coordination of multidisc

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