The cardiac surgery patient and the use of transitional care: Impact on post-operative complications and hospital readmissions. A structured narrative review.
Keywords:
Patient Readmissions, Post-operative Complications, Transitional Care, Cardiac Surgery, Continuous Nursing.Abstract
Background: Cardiac surgery patients are clinically and emotionally complex. Surgery represents a highly critical event not only for patients but also for their families. Care for these patients should not end at discharge; rather, ongoing support and education are essential. This underlines the relevance of Transitional Care (TC), characterized by nurse-led follow-up programs to ensure continuity of care and effective disease management post-discharge. However, the impact of such interventions remains poorly documented. This structured narrative review aims to assess the effectiveness of nurse-led follow-up models in managing post-operative complications and hospital readmissions in patients after cardiac surgery.
Study design: A structured narrative review was conducted to explore existing TC models and their effects on post-operative complications and hospital readmissions in patients discharged after cardiac surgery.
Methods: A comprehensive search strategy was implemented using PubMed and Cochrane Library databases, covering literature published from December 2014 to February 2025. The review was guided by the PIO framework: Population (adults undergoing cardiac surgery), Intervention (nurse-led Transitional Care programs post-discharge), and Outcome (reduction in post-operative complications and hospital readmissions). Studies were included if they were quantitative, experimental or observational designs, involved adult patients, evaluated nursing-led transitional care interventions and published in English. Studies involving pediatric populations, non-nursing interventions, or qualitative methods were excluded.
Results: After applying inclusion and exclusion criteria, seven studies were selected. Two main TC strategies were identified: post-discharge home visits and tele-nursing. These models were associated with improved medication adherence and reduced post-operative complications, including anxiety, depression, bleeding, thromboembolism, and lower hospital readmission rates.
Conclusions: Nurse-led TC interventions after cardiac surgery demonstrate promising potential to enhance recovery, ensure greater continuity of care, and reduce adverse events and healthcare system burden. Implementing structured follow-up TC programs can support sustained patient engagement, promote treatment adherence, and contribute to improved long-term outcomes.
References
1. Parry C, Mahoney E, Chalmers SA, Coleman EA. Assessing the quality of transitional care: further applications of the care transitions measure. Med Care. 2008;46(3):317-22. doi: 10.1097/MLR.0b013e3181589bdc.
2. Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51(4):556-7. doi: 10.1046/j.1532-5415.2003.51186.
3. Mardani A, Griffiths P, Vaismoradi M. The role of the nurse in the management of medicines during transitional care: a systematic review. J Multidiscip Healthc. 2020;13:1347 1361. doi: 10.2147/JMDH.S276061. PMID: 33154651.
4. Noel K, Messina C, Hou W, Schoenfeld E, Kelly G. Tele-transitions of care (TTOC): a 12-month, randomized controlled trial evaluating the use of telehealth to achieve triple aim objectives. BMC Fam Pract. 2020;21(1):27. doi: 10.1186/s12875-020-1094-5.
5. Kankaya EA, Bilik Ö. Investigation of the effect of nurse counseling with mechanical valve replacement patients. Res Theory Nurs Pract. 2024;38(1):105-23. doi: 10.1891/RTNP-2023-0054.
6. Bikmoradi A, Masmouei B, Ghomeisi M, Roshanaei G. Impact of tele-nursing on adherence to treatment plan in discharged patients after coronary artery bypass graft surgery: a quasi-experimental study in Iran. Int J Med Inform. 2016; 86:43-8. doi: 10.1016/j.ijmedinf.2015.12.001.
7. Nabagiez JP, Shariff MA, Molloy WJ, Demissie S, McGinn JT Jr. Cost analysis of physician assistant home visit program to reduce readmissions after cardiac surgery. Ann Thorac Surg. 2016;102(3):696-702. doi: 10.1016/j.athoracsur.2016.03.077.
8. Hall MH, Esposito RA, Pekmezaris R, Lesser M, Moravick D, Jahn L, et al. Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions. Ann Thorac Surg. 2014;97(5):1488-95. doi: 10.1016/j.athoracsur.2013.12.049.
9. Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1-10. doi: 10.7326/0003-4819-157-1-201207030-00003.
10. Kangovi S, Grande D. Transitional care management reimbursement to reduce COPD readmission. Chest. 2014;145(1):149-55. doi: 10.1378/chest.13-0787.
11. Angelica G, Carpico A. Il paziente cardiochirurgico: management clinico assistenziale. Milano: Edizioni Scientifiche; 2009.
12. Frasure-Smith N, Lespérance F. Recent evidence linking coronary heart disease and depression. Can J Psychiatry. 2006;51(12):730-7. doi: 10.1177/070674370605101202.
13. Sanità Informazione. Transitional care ICT in Italia [Internet]. Sanità Informazione; 2024. Available from: https://www.sanitainformazione.it/salute/transitional-care-ict-in-italia/ [Last accessed: 2025 Mar 3].
14. Li SL, Zhou SH, Lin YJ. The value of continuous nursing in patients after cardiac mechanical valve replacement. J Cardiothorac Surg. 2020;15(1):299. doi: 10.1186/s13019-020-01326-5.
15. Zhou SH, Huang ST, Xu N, Chen Q, Chen LW, Kuo YR. The application and value of continuous nursing in patients after coronary artery bypass grafting. J Cardiothorac Surg. 2020;15(1):168. doi: 10.1186/s13019-020-01210-2.
16. Coskun S, Duygulu S. The effects of nurse led transitional care model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46-55. doi: 10.1093/eurjcn/zvab005.
17. Davies S. Transitional care for the cardiac surgery population: development of a clinical practice guideline [dissertation]. Minneapolis: Walden University; 2018. Available from: https://scholarworks.waldenu.edu/dissertations/5068 [Last accessed: 2025 Jan 10].
18. Maleki M, Mardani A, Iloonkashkooli R, Khachian A, Glarcher M, Vaismoradi M. The effect of hospital-to-home transitional care using a digital messaging application on the health outcomes of patients undergoing CABG and their family caregivers: a randomized controlled trial study protocol. Front Cardiovasc Med. 2023; 10:1224302. doi: 10.3389/fcvm.2023.1224302
19. Tepsuriyanont S, Sayasathid J, Tangpanyawong C, Sudasut T, Prasitpaphada Y, Konkam K. Effects of a transitional care program on knowledge and self care behavior among patients undergoing cardiac surgery. Thai J Cardio Thorac Nurs. 2022;33(1):167 82. Available from: https://he02.tci thaijo.org/index.php/journalthaicvtnurse/article/view/251300 [Last accessed: 2026 Jan 15].
20. Danielsen SO, Moons P, Leegaard M, Solheim S, Tønnessen T, Lie I. Facilitators of and barriers to reducing thirty-day readmissions and improving patient-reported outcomes after surgical aortic valve replacement: a process evaluation of the AVRre trial. BMC Health Serv Res. 2020;20(1):256. doi: 10.1186/s12913-020-05125-5.
21. Paré G, Kitsiou S. Methods for literature reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth evaluation: an evidence-based approach. Victoria (BC): University of Victoria; 2016. p. 157-84.
22. Joanna Briggs Institute. Critical appraisal tools [Internet]. Adelaide: JBI; 2024. Available from: https://jbi.global/critical-appraisal-tools [Last accessed: 2026 Jan 3].
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Alessia Carucci, Fabio D'Agostino, Manuele Cesare (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.