Implementation of an Advanced Practice Provider-Led Postoperative Telephone Follow-Up Program After Cardiac Surgery: A Single-Center Quality Improvement Study

Purpose: Unplanned readmissions after cardiac surgery confer an increased risk for adverse outcomes. Early contact with health care providers has been shown to reduce readmissions. Herein, we present the design and early results of an advanced practice provider (APP)-led targeted calling service for postoperative patients. Methods: We performed an institutional quality improvement project with a scripted postoperative telephone call curated to identify and triage postoperative patients at risk for unplanned readmission. Beginning in 2025, patients were categorized as either low risk or high risk for readmission by our clinical discharge nurse coordinator and discharging APP. We attempted to contact all patients within the first 72 h of discharge to review vital signs trends, weight stability, fluid balance, rhythm disturbances, or wound healing complications with a scripted questionnaire. Patients with concerns are triaged at the discretion of the outpatient APPs, with priority given towards in-person assessment. Unplanned readmissions were then evaluated retrospectively, readmit reasons were captured, and readmission rates were compared from January 2021 through November 2025. Results: At our institution, readmission rates after open cardiac surgery have declined from 10.9% in 2021 to 9.50% through November 2025. Our Readmissions Working Group has also observed a consistent decrease in isolated coronary artery bypass grafting (CABG) readmission rates from >10% in 2021 and 2022 to 8.5% through November 2025. Pleural and pericardial effusions, arrhythmias, and wounds remain the prevailing reasons for readmission in our postoperative patients. Conclusions: An APP-led postoperative phone call quality improvement initiative with an early triage to nurse-practitioner clinic enabled our group to identify early deviations from the expected course of convalescence and enact timely interventions for our postoperative patients.