Abstract
This study is concerned with the rate of readmissions for patients with congestive heart failure (CHF), which happens within 30 days after one’s discharge from the hospital. The author examined whether an intervention of self-care education performed by nurses in the hospital before patients’ discharge could improve the outcomes of the discharge and reduce the rate of readmission. The quantitative analysis of the rates of readmission for patients with and without self-care training was performed to reveal the success of this intervention approach. The results show that this type of intervention reduces the rate of patient readmissions. CHF management should include education for patients to improve their health after discharge.
Introduction
Congestive heart failure (CHF) is among the main diagnoses associated with higher readmission rates. Under the Affordable Care Act, the 30-day CHF readmission rate is a priority quality measure for providers and it includes financial disincentives to improve post-discharge outcomes. On average, the elderly (>65 years) in the US are hospitalized over 9 million times annually, for $26 billion (Bradley et al., 2013). The high burden of hospitalizations is attributed to preventable readmissions related to weak post-discharge care transition and follow-ups. The impetus for hospitals to adopt evidence-based interventions to decrease the readmission rates lies in the quality-linked CMS penalties. Investment in collaborative programs that support smooth post-discharge transition can minimize preventable readmissions and enhance outcomes (Bradley et al., 2013). In particular, educating hospitalized patients or family on assessing patient needs and medication use and providing follow-up care are some possible interventions for decreasing unnecessary re-hospitalizations.
Background
The problem of high levels of readmission for patients with CHF requires attention. According to Feltner et al. (2014), almost 25% of Americans that are hospitalized due to heart failure are readmitted to the hospital in less than 30 days. This issue is complicated by the fact that subsequent admissions are linked to several preventable comorbid conditions and high health care costs. The readmission risk peaks at day three, but declines by 50% after a 38-day post-discharge period has elapsed (Driscoll et al., 2016). The CHF admission rate is an indicator of the quality of inpatient and follow-up care. Appropriate nurse-driven health system strategies are critical in reducing avoidable readmissions and costs.
Problem Statement
Statistics indicate that about 5.7 million adults in the US have CHF with the disease prevalence projected to reach 46% by 2030 (Ziaeian & Fonarow, 2016). Most CHF diagnoses require admission into the cardiac unit for specialized inpatient care. However, this condition is associated with higher readmissions within 30 days after discharge, estimated to be 25% nationally (Feltner et al., 2014). The number of unnecessary re-hospitalizations that can be avoided through hospital interventions is open to discussion. However, conservative estimates indicate that it is possible to prevent 5-79% of CHF readmissions through health system interventions (Ziaeian & Fonarow, 2016).
Implementing evidence-based interventions, such as patient education, post-discharge follow-ups, and collaboration with community physicians can help minimize CHF readmission rates. For inpatient care, the ACCF/AHA guidelines exist that support clinical decisions related to diagnosis, treatment, and prophylaxis (Ziaeian & Fonarow, 2016). However, despite most hospitals adopting the recommended CHF management guidelines, a significant number of patients seek readmission for emergency care within 30 days following discharge. Further, inpatient-outpatient care transitions appear to be inadequate. A significant number of CHF patients do not understand the peri-discharge alterations made to their medications, which increases medical error risk (Driscoll et al., 2016). Inpatient preparation can enhance outcomes and decrease the re-hospitalization rate. Nurse-led interventions that include a patient education component are associated with a 56.2% decline in the 30-day readmission rate (Driscoll et al., 2016).
Purpose
The purpose of this study was to decrease the rate of 30-day readmission of patients with CHF in a local hospital through nurse-driven inpatient self-care education before discharge. Research indicates that the intervention would result in lower risk-adjusted CHF re-hospitalizations and costs and enhance clinical outcomes (Driscoll et al., 2016). Specifically, the pre-discharge preparation entailed teaching patients about CHF pathophysiological features, medication use, and symptom monitoring at home. Readmissions were relatively high in this hospital, resulting in lower Medicare financial incentives.
Literature Review
The study employed the PDSA theoretical model to implement a change project to lower the 30-day readmission rate in the hospital. According to Cahill (2014), the PDSA model can help achieve continuous quality improvement by planning and executing (doing) a change initiative, studying its outcomes, and applying (acting on) the lessons learned in the organization. Iterative PDSA cycles result in incremental change in a specific clinical area. The model was used in the initial planning and implementation phases of the Capstone project at the facility. Further, the analysis of project outcomes was done during the study stage, while the results informed requisite improvements of the educational program to achieve lower CHF readmissions. Research-based on this framework shows that relevant inpatient education improves post-discharge clinical outcomes, reducing the number of patients readmitted with 30 days.
Bradley et al. (2013) propose several possible strategies for hospitals to lower the rate of readmission of patients with heart failure. For instance, the arrangement of follow-up visits to a hospital before discharge allows physicians to keep in contact with their patients and monitor their health. Alternatively, the authors state that many hospitals contact their patients to provide some additional information about their health for improved self-care at home. However, the authors do not examine the ability of self-education for patients before discharge.
Another collection of possible interventions can be found in the work of Feltner et al. (2014) who mention the possibility of education before discharge for patients with CHF. The authors note that this type of intervention is common in hospitals. However, the results of the study are inconclusive, as the researchers do not establish the effect of education. Dadosky et al. (2016) examined the impact of nurse-driven educational intervention on post-discharge readmission rates within 30 days. The training entailed direct patient instruction, financial challenges to effective care, and available outpatient networks or resources. From the results, the 30-day re-hospitalization rate was lower for the intervention group than the control (12% vs. 18%) (Dadosky et al., 2016). However, the study was limited by small sample size and a nonrandomized design (quasi-experimental).
In another study, Warden, Freels, Furuno, and Mackay (2014) compared the readmission rates of heart failure patients receiving pharmacist-led education (n=35) and control group subjects (n=115) in a hospital. This research found that the 30-day CHF-related re-hospitalizations after discharge were lower in the experimental group than the control group. Further, patients trained in medication reconciliation reported improved adherence and clinical outcomes compared to the unprepared subjects (Warden et al., 2014). As a result, pharmacist-led education was associated with lower readmission rates. However, this study was less comprehensive, as it only focused on one element of inpatient education – medication reconciliation. A broader intervention bundle could yield more informative results.
Arthur et al. (2015) implemented a two-year quality improvement project in a hospital to evaluate the impact of heart failure education on readmissions. The intervention bundle included a 60-minute educational sessions, CHF literature designed for inpatients, and a bedside training flow chart. The results after two years indicated a substantial drop in 30-day readmissions from 29% to 19% linked to the project (Arthur et al., 2015). The study found a strong correlation between a decline in the re-hospitalization rate and the implementation of the quality improvement project. However, it is not clear whether the drop in readmissions after the two-year educational program is evidence of causation.
An RCT by Kommuri, Johnson, and Koelling (2012) assessed baseline and post-intervention patient HF skills following a nurse-led education using a questionnaire. In this study, CHF knowledge was higher in the intervention group (n=113) than the control group (n=113) after the training. The authors concluded that peri-discharge CHF education improves patient understanding of self-management methods, minimizing the 30-day readmission risk. This finding for nursing practice implies that HF training by nurse educators is one way by which people diagnosed with this disease to care for their needs effectively and avoid HF-related emergency visits. However, the main weakness of this research is the use of a questionnaire instrument that had not been tested before.
In another study, White and Hill (2014) conducted a quality improvement project to test the effect of patient education on self-care. The second objective of this research was to reduce CHF readmissions and length of stay (LOS) through pre-discharge preparation. The researchers established that LOS declined to 4.42%, down from 6.1%, while the readmission rate dropped to 12.9% from a high of 23.1% (White & Hill, 2014). Thus, a multifaceted inpatient education can instill self-care attitudes in heart failure patients, resulting in better CHF outcomes. In this study, LOS was not a good indicator of training efficacy since the start of the sessions varied between patients.
A recent review by Ziaeian and Fonarow (2016) examined evidence-based interventions for decreasing HF readmissions and bolstering hospital performance. Based on CHF-management guidelines, effective medical therapies for managing CHF complications that occasion re-hospitalization include ACE/ARB inhibitors and gadgets like the implantable cardioverter defibrillators (Ziaeian & Fonarow, 2016). Further, evidence-based health system interventions for minimizing readmissions include nurse-driven patient/family education, medication reconciliation, and follow-up care (Ziaeian & Fonarow, 2016). However, no experimental study was conducted to establish the connection between these variables.
The literature supports the implementation of inpatient education as an intervention for reducing hospital CHF readmissions at the hospital. The main premise is that the lack of support at discharge and post-discharge results in poor self-care behavior. As a result, patients often present with preventable CHF-related complications at the emergency department within 30-days after discharge. Improved nurse-directed inpatient education is linked to lower readmission risk (Ziaeian & Fonarow, 2016). However, the studies do not evaluate the self-care knowledge of the patient before discharge. Adequate preparation and knowledge of the post-discharge treatment plan at discharge could improve clinical outcomes.
Research Methodology
Study Design and Sample
This research used a quantitative approach of comparing the rate of readmission between two groups of patients within CHF 30 days after their discharge. The first group (intervention) received self-care education before discharge, while the second group (control) consisted of unprepared patients. The number of subjects from either category seeking readmission for CHF-related complications was recorded between 01 September 01, 2017 through 31, October 2017.
A four-week inpatient self-care education was offered to a convenience sample of 12 patients with a CHF diagnosis. The study also included 10 unprepared subjects (control group). The exclusion criteria entailed patients not enrolled in Medicare or other transition plans. The study used the PDSA model to identify opportunities for educational intervention based on initial data. Before implementing the intervention, all nurses and CHF patients at the unit were informed about the project and its objectives.
Measures
Two variables were measured: CHF management and the rates of readmission. The HF educational content delivered by RNs focused on general CHF pathophysiology, common symptoms, medication/diet adherence, and risk factors – smoking and alcohol. The intervention bundle included CHF videos and literature on CHF management. The outcome measured included an improved patient understanding of self-care practices, such as symptom identification, adherence to medication and diet regimen, and enhanced management of CHF at home.
The self-care educational intervention involved one-hour sessions delivered by a registered nurse to hospitalized subjects receiving inpatient care. The discharge date was noted and subsequent admissions recorded. The RN documented each time a subject was readmitted at the hospital for heart failure-related complications. Data collected on hospitalization date, cause, and medication adherence were used to determine 30-day readmission outcomes. Patient demographic characteristics – educational level, age, gender, and marital status – were also obtained. The null hypothesis tested was that there would be no significant difference in the CHF readmission rate between patients receiving self-care education and unprepared ones on the first, second, third, and fourth week of the intervention.
Results and Analysis of Research Findings
This Capstone project implemented an RN-driven educational intervention in the CHF clinic to improve patient outcomes. The demographic characteristics of the participants and descriptive statistics were determined with the SPSS software. In this project, 12 and10 patients diagnosed with CHF took part in the intervention and control group, respectively. All the subjects who started the inpatient self-care education completed it. The demographic variables of the two study groups were comparable.
In the intervention group, the subjects comprised mainly older adults (53-77 years) and slightly more females (58.3%). Most of the participants were married (73%), while a few of them were either single (21%) or widowed (6%). All intervention group subjects were given CHF education taught by an RN. Further, the participants were all English-speakers (100%), and therefore, English was the language of instruction. A significant majority of them (66.7%) possessed a high school diploma or higher.
The control group (n=10) included patients with a CHF diagnosis who were not prepared through self-care education. Their baseline data were obtained from medical records. The age of the participants was 58-78 years (M =68.5). Overall, there were more males (60%) than females (40%) in this group. None of the subjects received self-care education before discharge. The majority of them were married (46%), while others were widowed (38%) or single (16%). The demographic data summary for the intervention and control groups is given in Table 1 below.
Table 1. A Summary of Demographic Characteristics.
During the project period, two out of 12 intervention subjects were readmitted within 30 days (8.3%). Also, of the 10 control participants, four were hospitalized after discharge (40%).
As stated, the project involved the implementation of an educational intervention to enhance the self-management of CHF patients to decrease readmissions at the hospital. Thus, frequency analysis was performed as shown in Figure 1. The graph shows that 7 and 14 days after discharge no intervention patient and 20% (n=2) of control subjects were re-hospitalized. After 21 and 30 days, only 8.3% of the participants who received self-management education required emergency care. In contrast, 40% of the unprepared patients were re-hospitalized within 30 days after discharge.
The mean age difference between the intervention group (M=65.4) and the control group (M=68.5) was not statistically significant. Further, the gender difference was comparable between the two arms. However, the frequency of readmissions was significantly different between prepared and unprepared patients (8.3% vs. 40%). This part of the research shows that the intervention of pre-discharge education is effective for patients with CHF. Hypothetically, the rate of readmission for persons who received self-care training before discharge was decreased in comparison to the unprepared patients.
Discussion of Hypothesis and Conclusion
The results of this study are discussed as the basis for further research. This project aimed to decrease CHF readmissions through a nurse-driven pre-discharge educational intervention at the hospital. The clinical question was; in patients diagnosed with CHF, does self-care education (intervention), compared to no pre-discharge preparation (control), reduce readmissions in a period of 30 days? It was hypothesized (null) that the difference in the 30-day re-hospitalization rate would not be statistically significant between the intervention group and the control group. On average, the number of heart failure patients readmitted within a month after discharge was 10-25.
The demographic characteristics of the sample were comparable between the two groups with the age of most participants being above 65 years, which may be a limitation of this project. The convenience sampling approach used on a single facility could account for the fewer number of participants aged 40 years and below. Further, the fact that the sample was mostly elderly with comorbid conditions could have affected the acquisition and retention rate of CHF management. Thus, age and comorbidities are possible confounding variables that could have impacted learning and utilization of self-care skills. However, gender distribution was not significantly different between the treatment and control arms.
Knowledge of CHF management allows patients to adhere to post-discharge guidelines, resulting in optimal health outcomes (Driscoll et al., 2016). The presence of family caregivers can also reduce the need for inpatient care. In this study, marital status as an indicator of family support in promoting patient self-care practices. As Feltner et al. (2014) note, family support encourages self-management behaviors, contributing to lower readmission rates. The majority of participants in the intervention group (73%) compared to the control group (46%) were married, which could explain why the number of patients who received the educational intervention being readmitted was lower than unprepared ones. This finding is consistent with those previous studies, whereby most intervention participants lived with family members (Feltner et al., 2014). The researchers further report that patients who are not living alone are more likely to adhere to medication than those indicating that they are single (Feltner et al., 2014). Future research should examine the correlation between the marital status of CHF patients and readmission outcomes.
In this study, the 30-day readmission rate was 8.3% for the intervention group compared to 40% for the control group. Before the implementation of the project, 10-25 patients (41%) were readmitted for CHF symptom exacerbations within 30 days. Thus, the educational intervention reduced the readmission rate by about a fifth (20%). The difference between the two groups was statistically significant (8.3% vs. 40%). This result is consistent with previous findings on peri-discharge educational intervention. For instance, White and Hill (2014) found a correlation between pre-discharge preparation and lower LOS and readmissions. In this study, the quality improvement project (self-care education) decreased LOS dropped from 6.1% to 4.42% and the re-hospitalization rate declined to 12.9% from 23.1% (White & Hill, 2014). Thus, discharge education is an evidence-based strategy for decreasing readmissions.
In conclusion, in the current project, education was required to prepare patients on self-care behaviors and improve outcomes. This evidence-based intervention included one-on-one sessions administered to hospitalized patients diagnosed with CHF during admission by RNs for three weeks. The control group only received standard discharge instructions. One key finding of this study was the outcome differences between patients living with a spouse and those staying alone. The availability of a supportive member was associated with lower readmission rates after 30 days. Therefore, family or spousal support improves post-discharge CHF management, including medication adherence and symptom monitoring. Informed consent was sought from all the participants before participation.
The study had some limitations related to sampling and the depth of the intervention. The amount of data was highly limited, as the project used information from a single hospital. More comprehensive and insightful findings could be obtained by implementing educational intervention in multiple facilities. The second limitation was related to the focus on one interventional strategy – patient education. Other types of interventions were not included in the analysis of the results, which could have affected the interpretation of the gathered data. The use of elderly participants (>65 years) was another limitation that may have affected the educational outcomes. This barrier resulted from the convenience sampling approach used, which inadvertently left out younger CHF patients.
The findings of this study have implications for nursing practice. Registered nurses teach CHF self-care management, track medication adherence, and assist patients identify and manage symptom exacerbations on time to avoid unnecessary readmissions. At the hospital level, efforts to improve quality and avoid financial incentives related to excessive 30-day readmissions should include an educational intervention. The strategy equips patients and families with self-management knowledge that translates into improved outpatient outcomes. The likelihood of prepared individuals being readmitted within 30 days is low. Ultimately, the educational intervention results in quality improvement, an increase in CMS incentives, and a decrease in hospital spending.
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