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D
espite advances in mates, 54% of readmissions may be
therapy, morbidity preventable, and inadequate dis-
and mortality remain charge planning and education or
high in patients hos- lack of patient follow-up are common
pitalized for heart factors in readmission.3-5 Lack of
PRIME POINTS failure. Although new approaches compliance with medications, fail-
to improving the use of guideline- ure to follow a salt-restricted diet,
recommended evidence-based and delays in seeking medical atten-
• Educating patients therapies at hospital discharge are tion are among the primary reasons
before discharge
undeniably needed,1 truly compre- for the high rate of rehospitalization
promotes self-care,
hensive and competent care for among patients with heart failure.6
reduces readmissions, patients hospitalized with heart fail- Patients who are not knowledge-
and helps patients spot ure requires a strong focus on edu- able about their disease and their
problems early. cation of patients and their families. medication are at a severe disadvan-
Education at discharge is a vital tage. In one study,7 the association
• Patients should be component of improving outcomes of medication adherence and knowl-
active partners in the in heart failure. The institution of a edge was tested in 61 patients age
management of their structured system of patient and 50 years or older who had heart
health. family education that involves a failure. Patients’ knowledge of the
multidisciplinary team and empha- dosage, frequency, and indication
• Patients should sizes medication adherence, sodium
and fluid restrictions, and recogni-
of each of their heart failure medica-
learn about their tions and patients’ ability to open
conditions and medi- tion of signs and symptoms that medication bottles, read labels, and
indicate progression of disease may distinguish tablet/capsule colors
cations and when to
be as important as ensuring that were assessed. Lower medication
seek medical treatment.
patients are prescribed appropriate adherence (P = .001) and an inabil-
medical therapy. Specific topics of ity to read labels (P = .002) were
• Nurses need to instruction for patients hospitalized significantly associated with an
understand the barri- with heart failure are listed in Table 1. increased number of cardiovascular-
ers to self-care and Poor adherence to these instructions related visits to the emergency
help patients overcome can lead to worsening of disease and department. Patients with greater
these barriers. rehospitalization. According to esti- medication adherence had a mean
Figure 1 American College of Cardiology/American Heart Association performance measure: discharge instructions.
Abbreviations: CMS, Centers for Medicare and Medicaid Services; HF, heart failure; ICD-9-CM, International Classification of Disease, Ninth Revision, Clinical Modifi-
cation; JCAHO, Joint Commission.
Reprinted with permission from ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure: A Report of the American College of Cardiol-
ogy/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures)
Endorsed by the Heart Failure Society of America.
©2005, American Heart Association, Inc.
with heart failure receive written reviewed to determine the percentage Diet: 70% (range, 58%-94%)
instructions or educational material of patients who receive the quality of Exercise: 61% (range, 26%-81%)
at discharge that will adequately care indicators derived from the clini- Smoking cessation: 14% (range,
address all of the components cal practice guidelines of the Agency 0%-33%)
mentioned in the guidelines.10 The for Health Care Policy and Research. The variability of counseling
intention is that through use of A total of 1623 hospitalizations for between hospitals was high, and
these performance measures, the heart failure were reviewed; the mean documentation may not reflect what
quality of cardiovascular care will frequencies of documentation of was actually practiced.12 The docu-
be improved.11 However, conformity counseling about medications, mentation may or may not have
with these indicators among health weight, diet, exercise, and smoking reflected the extent of the counsel-
care providers is not guaranteed. cessation were as follows: ing. How the information was con-
In 1997, medical records from Medications: 97% (range, 95%-98%) veyed and the depth of the patient’s
9 hospitals were retrospectively Weight: 6% (range, 3%-12%) understanding of the information
- Pain
Exercise/Activity/Diet/Prescription Information Given: See back for health education and resources
If you smoke, STOP! (Smoking will make heart disease worse and may cause death.)
☐ Booklet Given, see back ☐ Does not smoke - or - Has not smoked in more than 12 months
☐ AMI/CHF Discharge Packet Given ☐ Home Exercise Program Instruction Provided
☐ Drug info/food/drug interaction info provided ☐ Cardiac Rehab Information Provided
☐ Daily Weights Instructions Given-See back Cardiac Rehab Ordered ☐ Yes ☐ No
☐ Diet __ Low Sodium, Low Cholesterol, high fiber Your Total Cholesterol: ___
☐ Resources on back reviewed ☐ Driving Instructions Given
May Return to Work on (date) ___________________ ☐ Activity: Light activity until follow-up appointment
Follow-Up appointment:
___________ Dr.: ___________________________ Phone: ___________________________________ Date: ___________
I have received a copy of this form and understand the instructions. Patient signature ______________________________________
NOTE: Any old, unused pills or liquid at home should be flushed down the toilet. Please discuss with your doctor any medications
(including over the counter pills or liquid not ordered by the doctor) you have been taking at home if they are not listed above.
KEEP THIS FORM AND BRING IT WITH YOU TO ALL FOLLOW-UP DOCTOR APPOINTMENTS
Figure 2 The American Heart Association Get With the Guidelines heart failure discharge tool.19
Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; CHF, congestive heart failure; CM,
case manager; info, information; MD, physician; rehab, rehabilitation; RN, registered nurse.
Patient’s name:
suggestions. Cookbooks and Web assist them.36 Education and coun- Results of studies24,37 on alcohol use
sites with low-sodium recipes can be seling sessions to promote behavior among patients with heart failure
helpful to patients and their spouses change, referral to smoking cessation indicate that 25% to 40% of patients
as they plan meals (Table 2). Lists of programs, and recommendations to with heart failure do not understand
foods to avoid, foods to enjoy in use nicotine replacement substances the risks of alcohol consumption.
moderation, and foods that are may be key to helping patients with Efforts to educate patients about the
within dietary guidelines should be nicotine addiction. Medications detrimental effects of alcohol on
readily available for patients, along that promote smoking cessation, cardiac function should be reinforced,
with lists of substitutes or alterna- such as bupropion or varenicline, and resources should be provided
tives to high-sodium foods. should be used with extreme caution, that can facilitate alcohol-withdrawal
Although smoking can contribute and patients
to increased risk for multiple hospi- should be
tal admissions, most patients lack closely moni- Table 2 Web sites offering low sodium recipes and food
suggestions
motivation to stop smoking ciga- tored during
www.lowsaltfoods.com
rettes.29 Despite medical counseling therapy.
and awareness that smoking induces Similar www.alsosalt.com/lowsodiumfoods.html
illness, the relation between medica- daily life) both in the hospital and 1 (t=4.9, P<.001) but not in the con-
tions and illness, the relationship week after discharge. In addition to trol group (t=1.9, P=.06).
between health behaviors and ill- evidence-based education such as
ness, early signs and symptoms of recognition of warning signs and Social Support
worsening heart failure, and when symptoms of worsening heart fail- Support from people close to a
and where to obtain assistance. ure, problems of individual patients patient with heart failure is often
Patients’ understanding of the top- such as social interaction, sexual important to success. For example,
ics was assessed and reviewed to function, and limited access to the patients who are married tend to
provide information about gaps in general practitioner were discussed. have a greater knowledge about their
patients’ knowledge for the nurse to During the hospital stay, the study disease.24 The self-management of
address. In subsequent follow-up nurse assessed each patient’s needs, dietary restrictions is difficult and
sessions (by telemonitoring), the provided education and support to usually occurs within the context of
nurse reviewed knowledge and the patient (and the patient’s fam- family; therefore, a family education
provided support for patients to ily), gave the patient a card listing intervention was tested for the effect
reinforce the initial educational the warning signs and symptoms, on improving self-management
foundation, theoretically by and discussed discharge. Within 1 related to sodium intake.53 Patients
empowering patients and offering week after discharge, the study with heart failure and a family
strategies to improve adherence. nurse telephoned the patient to member received either (1) in-depth
The intervention was associated assess potential problems and rein- education and counseling (in both
with a 39% decrease in the total forced and continued education as verbal and written form, a video on
number of readmissions.51 warranted. One month after dis- heart failure care, and individualized
In another study,52 179 patients charge, patients from the interven- dietary discussion and feedback to
with heart failure were randomized tion group reported complying with promote knowledge as well as self-
either to usual care or to a nurse 14 of the 19 self-care behaviors, vs efficacy in selecting and preparing
education initiative (consisting of 12 behaviors for the control group. low-sodium foods) by a nurse expert
intensive, systematic, and planned The increase in self-care behavior and a dietitian or (2) the same in-
education by a study nurse about from baseline to 9 months was sig- depth education, counseling, and
the consequences of heart failure in nificant in the intervention group feedback by the same research nurse
•
improve the process of care, less overcome those barriers. A dis-
d t attention has been paid to the com-
prehensive strategies provided by
charge management program led
by a cardiac nurse that incorporates
To learn more about providing care for
patients with heart failure, read “Evidence- specially trained nurses that have the latest evidence, guidelines, and
Based Nursing Care for Patients With Heart improved outcomes for patients with tools can substantially improve the
Failure” by Nancy Albert in AACN Advanced
Critical Care, 2006;17(2):170-183. Available at heart failure. When studied in the level of care for patients with heart
http://www.aacnclinicalissues.com. context of multidisciplinary teams, failure. CCN
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