Developing a Question
In elderly patients (P), does receive congestive heart failure education with a post-discharge follow-up (I) compared to not receiving one (C) decrease the risk of heart failure readmissions (O) within a month’s time post-discharge (T)?
Identifying a Problem
Setting
The problem of educational deficit in relation to congestive heart failure (CHF) in elderly patients can be observed in an acute care setting. The issue of CHF is ever-pressing as it affects more than 5.8 million Americans, and about 670,000 are newly-diagnosed on a yearly basis (White, Garbez, Carroll, Brinker, & Howie-Esquivel, 2013). The risk factors of the disease include advanced age, which is why determining the way to decrease the readmission rates among elderly patients is imperative. The educatory context of the issue is complexified by the fact that there are no unified, efficacy-tested means of post-discharge CHF patient education.
Description
CHF is the most common hospitalization cause for American Medicare clients. The readmission rates nationwide are 24.7%, as per Medicare’s average in 2012 (Berk et al., 2013). For health care establishments, readmission within 30 days’ time is a problem, specifically for the acute care dealing with difficult patients as the treatment and maintenance of such patients can be costly, and the reimbursements for such readmissions are cut, as established by Section 3025 of the Affordable Care Act (Gosselin, Hanson, Kapadia, Lin, & Nash, 2014). For the patients and their relatives, the problem of readmission is understandably significant as the readmission indicates errors at some stages of the health care process.
Apart from advanced age, the risk factors associated with patient readmission include HF with preserved ejection, high BNP on initial hospitalization, and low systolic BP (Berk et al., 2013). Additionally, the higher-risk patients are likely to experience a more significant reduction of heart rate during the hospital stay; such patients are also likely to retain body mass. Such patients should be the target groups of CHF education as opposed to those with lower BNP and higher systolic blood pressure but these factors have not been formulated until relatively recently and are not acknowledged widely.
Patient education has been decided upon as the means to reduce the risk of readmission. The necessity of self-care communicated to elderly patients and their relatives is justified because the lack thereof is likely to aggravate the symptoms. Patients have to be aware of the signs of heart failure as well as the time and the dosage of medication they take to prevent under- and overdose. Teach-back has been commonly acknowledged as an effective teaching practice in nursing; the patients report high levels of understanding and are more likely to preserve the knowledge they obtain through communication and reproduction of the information.
However, studies indicate that the teach-back method, albeit effective, does not reduce readmission rates for CHF clients (White, Garbez, Carroll, Brinker, & Howie-Esquivel, 2013). The cause of it might be the limited duration of education sessions, but for the most part, the barriers to CHF management consist of constrained post-discharge follow-up (Gosselin, Hanson, Kapadia, Lin, & Nash, 2014).
Impact
Presumably, the impact of the lack of post-discharge follow-ups exacerbates patient outcomes because unattended, they might fail to recognize the symptoms and the necessity to refer to their provider or call 911 on time. The failure to care for oneself increases the risk of readmission with subsequent complications and lowers the chances to survive the acuity. In turn, hospitals are affected by increased readmissions because, as said, the reimbursements for repeatedly admitted patients are cut. Readmissions, therefore, are likely to harm the health care establishments in financial terms as well as shatter the morale of the nursing staff.
Gravity and significance
Educating the patients to spot the alterations in body mass, recognize escalating symptoms (e.g., dyspnea, wheeze, cough, edema, fatigue, nausea, heart rate increase, etc.) is imperative to allow for the care provider or the patient themselves to take measures as soon as possible. Ideally, the patients’ understanding should be ensured by the providers who cater to the education and counseling in the unit pre-discharge, and the education should be the task of RNs experienced in HF management.
However, the problem with patient education and its impact on readmission rates within a 30-day period post-discharge is not constituted by the lack of education sessions per se. The problem is specifically pressing because the diagnosis rates are high, and, in spite of the extensive body of existing literature on the subject of geriatric patient education, the one most effective model remains unknown (White, Garbez, Carroll, Brinker, & Howie-Esquivel, 2013).
Proposed solution
A recent study confirmed the efficacy of a follow-up on an outpatient basis within no more than 7 days post-discharge (Lee, Yang, Hernandez, Steimle, & Go, 2016). Based on the literature reviewed in the preceding sections, the follow-up could be made obligatory for higher-risk patients, i.e., those with HF with preserved ejection, high BNP on initial hospitalization, and low systolic BP. As to the persons responsible for the follow-up and education, an RN with experience in CHF management could attend to such patients.
References
Berk, M., Sundstrom, G., Rush, D., Harper, J., Miller, K., & Aryal, S. (2013). Factors Associated with an Increase in 30-Day Readmission Rate for Congestive Heart Failure. Journal of Cardiac Failure, 19(8), S84.
Gosselin, J., Hanson, J., Kapadia, S., Lin, M., & Nash, B. (2014). Congestive Heart Failure Patient Education Intervention to Address 30 Day CHF Readmission. Public Health Projects, 2008-present, 204, 1.
Lee, K. K., Yang, J., Hernandez, A. F. Steimle, A. E., & Go, A. S. (2016). Post-discharge Follow-up Characteristics Associated With 30-Day Readmission After Heart Failure Hospitalization. Medical Care, 54(4), 365-372.
White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “Teach-Back” Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients? Journal of Cardiovascular Nursing, 28(2), 137-146.