[AVBC 2025] Evaluating Advanced Practice Nurse (APN)-Led Follow-up for Fluid Overload
Care Process & Redesign
Technology
Appropriate & Value-based Care Conference
SingHealth
19 November 2025
To evaluate the impact of an APN-led follow-up initiative for patients with fluid overload from heart failure (HF) and/or. APN-led follow-up has demonstrated potential in reducing 30-day readmission rates and enhancing continuity of care for high-risk.
Year Submitted: 2025
Published Date: 19 November 2025
Tags: Readmission Rate, Access To Care, Care Process ＆ Redesign, Tele-Consultation, Telehealth, Digital Health, Technology, Nursing Home Care
About this Content
Aims
To evaluate the impact of an APN-led follow-up initiative for patients with fluid overload from heart failure (HF) and/or chronic kidney disease (CKD) on 30-day readmission rates and continuity of care.
Background
Fluid overload is a common and recurring complication in patients with HF (Heart Failure) and/or CKD (Chronic Kidney Disease), leading to hospital readmissions and increased burden on healthcare systems. This pilot initiative employed APNs to lead a structured follow-up care model using teleconsultation, with the aim of delivering patient-centred care.
Methods
The APN-led follow-up was piloted between August 2024 to May 2025, 16 patients were enrolled. The intervention consisted of utilising teleconsultation to follow up on the following: Review symptoms and fluid status, Review biochemical parameters, Medications titration, Fluid overload education reinforcement, Coordinate medication delivery, Patients demographics, Readmissions within same year prior APN-led follow up.
Results
Among the 16 patients on APNled teleconsultation follow up, 1 experienced 30-day fluid overload readmission, resulting in readmission rate of 6.3%.
Conclusion
APN-led follow-up has demonstrated potential in reducing 30-day readmission rates and enhancing continuity of care for high-risk patients with fluid overload.
Lessons Learnt
Teleconsultation reduces the need for patients to attend physical clinic appointments, offering a more convenient and accessible follow-up approach without compromising clinical oversight.
Keywords
Nurse Led, Care Continuity, Heart Failure, Chronic Kidney Disease, Fluid Overload
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Singapore General Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Nursing, Medical |
Applicable Specialty or Discipline | Nephrology, Cardiology |
Project Lead(s) | Leong Ee Won |
Project Member(s) | Helen Law Fung Lun |
Connect with this contributor!
Leong Ee Won - leong.ee.won@sgh.com.sg