Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence? (2008)

What are the barriers to self-care and how do nurses help patients overcome these barriers?Despite advances in therapy, morbidity and mortality remain high in patients hospitalized for heart failure. Although new approaches to improving the use of guideline-recommended evidence-based therapies at hospital discharge are undeniably needed,1 truly comprehensive and competent care for patients hospitalized with heart failure requires a strong focus on education of patients and their families.Education at discharge is a vital component of improving outcomes in heart failure. The institution of a structured system of patient and family education that involves a multidisciplinary team and emphasizes medication adherence, sodium and fluid restrictions, and recognition of signs and symptoms that indicate progression of disease may be as important as ensuring that patients are prescribed appropriate medical therapy. Specific topics of instruction for patients hospitalized with heart failure are listed in Table 1. Poor adherence to these instructions can lead to worsening of disease and rehospitalization. According to estimates, 54% of readmissions may be preventable, and inadequate discharge planning and education or lack of patient follow-up are common factors in readmission.3–5 Lack of compliance with medications, failure to follow a salt-restricted diet, and delays in seeking medical attention are among the primary reasons for the high rate of rehospitalization among patients with heart failure.6Patients who are not knowledgeable about their disease and their medication are at a severe disadvantage. In one study,7 the association of medication adherence and knowledge was tested in 61 patients age 50 years or older who had heart failure. Patients’ knowledge of the dosage, frequency, and indication of each of their heart failure medications and patients’ ability to open medication bottles, read labels, and distinguish tablet/capsule colors were assessed. Lower medication adherence (P = .001) and an inability to read labels (P = .002) were significantly associated with an increased number of cardiovascular-related visits to the emergency department. Patients with greater medication adherence had a mean (standard deviation) of 0.22 (0.73) visits to the emergency department per patient compared with patients who were less adherent, who had 1.00 (2.47) visits per patient. Overall, greater knowledge of, skills with, and adherence to medication were associated with fewer visits.Education of patients at discharge promotes self-care, reduces readmissions, and helps patients identify problems early, increasing the chances for intervention and improved outcomes. In this article, I discuss the importance of educating patients and their families in preventing rehospitalization for heart failure. I also address the use of performance measures to improve patients’ outcomes and methods for promoting retention of discharge instructions.Performance measures are criteria used by organizations to determine whether an organization is fulfilling its vision and meeting its patient-focused goals. These measures are standardized to evaluate hospitals and health care systems, regardless of location, in order to promote positive outcomes in patient care. Performance measures may reflect medical management of patients, but they may also assess aspects of patient care, such as education of patients and their families at discharge. The latest guidelines for management of heart failure from the Heart Failure Society of America recognize the importance of education and recommend that patients receive educational materials as part of the patients’ complete discharge instructions.8 These materials should address recommended activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if signs or symptoms worsen.2,8,9The American College of Cardiology/American Heart Association (ACC/AHA) Clinical Performance Measures for Adults With Chronic Heart Failure9 include the following inpatient performance measures for patients with heart failure: discharge instructions, evaluation of left ventricular systolic function, angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker for left ventricular systolic dysfunction, adult smoking cessation advice/counseling, and anticoagulant at discharge for patients with atrial fibrillation. The guidelines recommend that the clinical care team collect data and review compliance with these measures on a routine basis, look for changes, and adjust practice patterns as necessary to improve performance. The performance measure of discharge instructions and its components are shown in Figure 1.9The Joint Commission evaluates 4 performance measures for patients with heart failure that are similar to those of the ACC/AHA: discharge instructions (HF-1), assessment of left ventricular function (HF-2), use of angiotensin-converting enzyme inhibitors in patients with left ventricular systolic dysfunction (HF-3), and smoking cessation counseling (HF-4). These Joint Commission core measures require that patients with heart failure receive written instructions or educational material at discharge that will adequately address all of the components mentioned in the guidelines.10 The intention is that through use of these performance measures, the quality of cardiovascular care will be improved.11 However, conformity with these indicators among health care providers is not guaranteed.In 1997, medical records from 9 hospitals were retrospectively reviewed to determine the percentage of patients who receive the quality of care indicators derived from the clinical practice guidelines of the Agency for Health Care Policy and Research. A total of 1623 hospitalizations for heart failure were reviewed; the mean frequencies of documentation of counseling about medications, weight, diet, exercise, and smoking cessation were as follows:Medications: 97% (range, 95%–98%)Weight: 6% (range, 3%–12%)Diet: 70% (range, 58%–94%)Exercise: 61% (range, 26%–81%)Smoking cessation: 14% (range, 0%–33%)The variability of counseling between hospitals was high, and documentation may not reflect what was actually practiced.12 The documentation may or may not have reflected the extent of the counseling. How the information was conveyed and the depth of the patient’s understanding of the information were not documented. More recently, data from 81 142 admissions of patients with heart failure in the Acute Decompensated Heart Failure National Registry (ADHERE) were analyzed to determine rates of conformity with the 4 core performance measures from the Joint Commission.13 The median rate of conformity with discharge instructions (HF-1) was only 24% (range, 0%–99%), and the median rate of conformity with HF-4 (counseling for smoking cessation) was 43.2% (range, 0%–100%). A substantial gap in overall performance is apparent among hospitals. The establishment of educational initiatives and quality improvement systems to reduce this variability may substantially improve care.The relationship between current ACC/AHA performance measures for patients hospitalized with heart failure and clinical outcomes was investigated in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF), a registry and performance improvement program for patients hospitalized with heart failure. Only use of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker at discharge was associated with a reduction in mortality or rehospitalization at 60 to 90 days after discharge.14 Trials comparing conventional management of heart failure with management programs that included counseling of patients about diet, exercise, medications, and monitoring have shown that disease management programs can reduce hospital stays and improve functional status.15 However, these programs often involve outpatient programs, such as clinics or home visits, that are beyond those normally assessed in the ACC/AHA performance measure on discharge instructions. It is unclear whether the discharge instruction performance measure as recorded in the hospital reflects whether the patients did or did not receive each defined component of education. Patient education may be documented in the medical record even if the education was cursory and allowed little time for the patient to absorb and retain the information.15 Conversely, many patients and their families are not ready to learn at the time of diagnosis, regardless of how thorough the instructional session may be. Extensive education may be better absorbed when a patient is in a stable condition and has adapted to living with heart failure.16In the analysis of data from OPTIMIZE-HF, the discharge instruction performance measure did not have an effect on mortality or rehospitalization at 60- to 90-day follow-up.14 Fonarow et al14 concluded that current performance measures related to heart failure, other than the prescription of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker at discharge, have little effect on patients’ outcomes after discharge. education of assessed the of patients who did and did not receive the of components from the Joint Commission performance measure (HF-1) and analyzed whether of this measure was of other of discharge for the core measure (HF-1) was not all components level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if signs or symptoms were documented. that complete instructions be to patients with heart failure hospital discharge, the intervention to and were of the of components was significantly in the of patients who improvement measures better methods for and performance measures related to heart failure may be to improve care and outcomes of patients with heart that in discharge education is not as an component of care for patients with heart failure. A of medical records at a hospital of patients with heart failure that discharge counseling about medication adherence, sodium and the importance of weight monitoring was to only and of patients, The number of patients who are education may important to morbidity and and instructional may improve the and quality of discharge education. The With the heart failure program is a quality improvement program in to promote the use of guidelines for patients with heart disease and than hospitals are in the A component is the Patient a assessment and system that and evidence-based helps patients’ care by of current guidelines at data medication to the patient’s patient education materials discharge, and patient and of the discharge instructions is shown in Figure education as part of the overall discharge many hospitals are the from the With the heart failure program care, the of is not to evidence-based In a of how core measures from the Joint Commission are at a of standardized order discharge instructions, and education materials did not lead to improvement in for core The improved only after the of a heart failure and who used the standardized discharge instructions, and the education of the heart failure team to and to a of educational materials may a patient’s ability to absorb and programs the and for education at patients’ after discharge from the patients will education through follow-up educational or of the of information that is at the time of hospital be a component of multidisciplinary care to heart failure The team to education of patients patients’ outcomes. In one an intervention of patients education from a a and a with written These patients an as as a follow-up from the and the patients’ planning was with home health who the instructions in the Patients in the who did not have to the did not receive and did not have routine after discharge, and did not receive home visits from nurses in management of heart failure. rates were 4 in the of patients who care than in patients in the intervention patients in the care visits and than as many home health visits than did the patients in the intervention The for the intervention was management of heart failure often requires such as in and compliance with a medication and the to assess and signs and at patients all of the of their disease and may be patients have of knowledge of their disease and lack a understanding of heart failure and In a of knowledge in patients with heart failure, of the patients information or about self-care from health care of patients little or and only 14% about heart failure. of the patients did not recognize the importance of and did not the of Although of the patients they should the of in their diet, only patients’ barriers to may nurses to educational approaches a is from educating patients and their Patients and their families should be as in not as patients in the and their are they may that the information is to their should not be a but should patients in their who patients should receive to that the educational information is among all the information among the patients and their families can patients may be about their disease and may be about their ability to self-care they are of time should be allowed for patients to as they the new and should be at the for patients to as they of Patients and family should be a number that they may to to a if they have or problems after discharge. that they will receive follow-up home visits or may their and and patients to absorb information and should be included in when patients do not have of the The should be if a patient has may the may be for patients of and should be to patients to their remain a should be to help patients that are to the patients’ but in such as or are high in and should be to should be for patients and their families and should their barriers to such as functional and and The reasons for in following a prescribed are but barriers to self-care and adherence may include a medication that is to the that for the patient to instructions, or the lack of to follow discharge with heart failure are often with medication the of patients’ understanding of the for each medication may be and their ability to follow instructions may be can be as high as for medication and for In a of admissions for heart failure, with medications and to sodium retention and was the in of the of the patients were with medications, diet, or In a of patients with hospital the rates of with smoking and from were as high as and may be increased by improving patients’ understanding of the importance of the and by through the use of to reduce the of patient’s ability to and what or was at discharge is patients often have in to heart failure that can to and with therapy. 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Patients should be to with that their methods and of patient education are and may be important to outcomes. of patients of with assessment of a patient’s level, and the patient’s and barriers to be The with the patient to the educational intervention and goals. In the the education and information is to the patient and the patient’s family as The evaluation of the that with the patient’s level, and by a to compliance among for improving patients’ adherence are listed in Table are to the of education and can the of discharge instruction and better outcomes by better education with heart failure recognize the importance of discharge education. about what information is patients information on medication and signs and symptoms as by education about heart failure, and The of patients from patient to on Patients’ educational their ability to written and the of written barriers be in material be written at an appropriate that will the of a of in one that an educational intervention written materials at patients with than and was associated with in self-care and signs and symptoms related to heart between a or multidisciplinary team and a patient are an important component of education at discharge. In a of patients with heart failure, compared the of a session with a with the of the discharge by the Patients in the education also a of the guidelines for heart failure written in Patients the educational intervention had a of rehospitalization or The intervention patients also increased self-care with they were to of intervention patients of follow a = and smoking = was to determine the effect of a education and intervention on or mortality and of care for patients hospitalized with heart failure. The intervention of an an session each patient’s knowledge of the the between medications and the relationship between health and signs and symptoms of worsening heart failure, and when and to Patients’ understanding of the topics was assessed and reviewed to information about in patients’ knowledge for the to In follow-up the reviewed knowledge and for patients to the educational by patients and to improve The intervention was associated with a in the total number of patients with heart failure were to care or to a education of and education by a about the of heart failure in in the hospital and after discharge. In to evidence-based education such as recognition of signs and symptoms of worsening heart failure, problems of patients such as function, and to the were the hospital the assessed each patient’s education and to the patient the patient’s the patient a the signs and and discharge. after discharge, the the patient to assess problems and and education as after discharge, patients from the intervention with of the self-care for the The in self-care from to 9 was in the intervention but not in the from to a patient with heart failure is often important to patients who are to have a greater knowledge about their The of is and the of a family education intervention was tested for the effect on improving related to sodium Patients with heart failure and a family education and counseling and written a on heart failure care, and and to promote knowledge as as in and by a and a or the and by the and on family and patients’ through and sodium and of a of sodium were at and after the had in sodium and sodium in the at the with the that on family had greater in the of sodium in the to in the intervention to in the and had a greater percentage of those with in of sodium in the of intervention patients of patients, intervention is one that the of a and a A management intervention was to care and to help patients with heart failure to improve their quality of practice nurses the included and follow-up with The intervention was by from the about their and information from the Patients high with the was defined as and a the intervention was patients were to and a but did not follow through in and the to and should be for to how these factors and with a may and improve the quality of of patients with heart after can the education that was at discharge. In a of care after discharge, the intervention a the patient at home after discharge to the patient about heart failure and the A reduction in heart failure and readmissions was in those patients the follow-up at home compared with the In a of patients to follow-up at a heart failure or care, fewer patients in the intervention than in the or had to be to the hospital after patients a after and to evaluate their self-care and the intervention significantly than the did after and after assessed the of a disease management program that discharge of therapy, improved attention to signs and and and hospital admissions for heart failure were in the intervention than in the with patients in the intervention in functional quality of and rate of prescription of monitoring is a to education and assess patients’ of the of by practice nurses was in patients with heart therapy, the nurses patients about the of how to a and monitoring a patients their vital and symptoms to the nurses by The practice nurses and patients to the of the was a of this of patients a and of patients of in hospitalizations for heart failure this included of monitoring structured to determine if such monitoring improved outcomes in patients with heart failure. monitoring programs the rates of hospital admissions related to heart failure by and the rate of mortality by such as can be to improve education but should be used as an to a comprehensive educational discharge they may have on a of the mentioned investigated the of a comprehensive educational program that included a of inpatient and outpatient education. The comprehensive an educational the in one patients with heart failure were to receive care or a intervention that included a review of patients’ and their medications, home visits, and follow-up 90 days after discharge, the multidisciplinary intervention had admissions by (P = compared with care, and admissions for heart failure were by (P = a of the of comprehensive management of patients with heart failure, the intervention of an who a education program for with heart failure with comprehensive discharge planning and outpatient through a home health care to 60 the rate for heart failure in the was the rate in the intervention the rate in the was 4 the rate in the intervention of hospitalized patients with heart failure who were to a comprehensive intervention or care, the intervention included educating patients about the disease and its in how to adjust of as as home visits, monitoring of each and of Patients in the intervention had fewer admissions than did patients in the had fewer admissions for heart failure and significantly fewer days in the hospital for heart failure days = of the has to programs to improve the of care, less attention has to the comprehensive by nurses that have improved outcomes for patients with heart failure. in the of multidisciplinary significantly to improving outcomes. In a review of of multidisciplinary management programs, et that of the to a program is the use of nurses who are knowledgeable about heart comprehensive discharge education to patients with heart failure is to improving and nurses are in a to on the of Patients with heart failure should their their medications, and when to medical is about the important of education and self-care on patients’ the to from the of patients as of information is Patients should be as in the management of their nurses a in the educational and can be the primary who and evaluate patients’ self-care include weight monitoring, sodium and fluid restrictions, medication monitoring signs and symptoms of disease and for medical care. nurses should to the barriers to patient adherence and self-care and learn to patients to overcome those A discharge management program by a that the latest and can substantially improve the of care for patients with heart failure.