Shortness of breath and fatigue are chronic, progressive symptoms of heart failure (HF). As incidence and prevalence of HF grows, healthcare providers need to develop strategies addressing postdischarge self- management to prevent exacerbations of conditions that lead to hospital readmission.
There are a number of healthy lifestyle factors known to control HF. These include taking prescribed medication as directed, maintaining a low-sodium diet, paying attention to fluid intake, increasing activity as tolerated with rest, monitoring daily weight and symptoms, reporting abnormal findings to healthcare personnel, and following up consistently with providers.
The Centers for Medicare and Medicaid Services has assessed and published 3-year aggregate 30-day readmission rates for HF (all causes) beginning in June 2009, as part of its quality initiatives under the Reporting Hospital Quality Data for Annual Payment Update program. The purpose was to motivate hospitals across the United States to improve quality and efficiency of care. The time periods assessed were July 1, 2005 to June 30, 2008, and July 1, 2006 to June 30, 2009.
Data were derived from Medicare recipients over age 65 who received benefits for at least 1 year, survived hospitalization, weren't on hospice care, and didn't leave the hospital against medical advice. The information was collected across all hospitals in the United States that received Medicare reimbursement. Results for each time period demonstrated a U.S. national mean HF 30-day readmission rate of 24.5% and 24.7%. In fact, a past report demonstrated an almost 50% readmission rate within a 6-month period due to HF.
Reasons for readmission
About 50% of patients who present in the ED with HF symptoms have been noncompliant with dietary or medication regimens. A number of researchers have demonstrated that patients generally have a poor understanding of HF and its symptoms and treatments, creating communication difficulties. These difficulties may affect the patient's ability to self-manage HF, and inadequate communication with physicians may contribute to the problem.
Transportation issues, confusion, short-term memory loss, overall poor cognition, depression, fatigue, poor family functioning, and medication adverse reactions also interfere with a patient's ability to self-manage HF.
Did they take their meds today?
Results of a large number of randomized clinical control trials and meta-analyses, along with nationally recognized clinical practice guidelines, indicate that morbidity and mortality from left ventricular systolic dysfunction could be significantly reduced through the use of standard medication or a combination of medications. There's evidence that medication adherence affects the severity and course of HF; medication adherence levels range from 7% to 85%.
A study of initiation and persist ence of HF medication in 107,092 patients between 1995 and 2004 proved that poor adherence with pharmacologic HF regimens is a common problem and influences prognosis. The investigators found that adherence was high after medication was started and remained at 79% after 5 years. Nonpersistence was associated with increased mortality.
Patients generally described themselves as adherent to medications, although findings from studies using objective methods rather than subjective reports seem to contradict these statements. Self-reported reasons for poor medication adherence included high medication costs, memory problems, lack of self-administration knowledge, and poor health.
Monitoring daily routines
Symptom worsening, such as progressive dyspnea, is a signal to chronic HF patients that readmission may be imminent. Still, many patients attempt counterintuitive and diverse strategies to self-manage HF before contacting their healthcare provider, such as self-medicating, reducing the frequency or pace of physical activity, waiting for breath between activities, dimming lights, using a fan to improve breathing, or elevating the legs. This may be due to misperceptions related to self-care or lack of knowledge about symptom meaning.
Daily weight monitoring is a critical source of information to help patients determine when they may be retaining fluid, which can cause HF decompensation. Daily weight monitoring was done less than half of the time to monitor fluid status in a study of HF patients.
Monitoring dietary sodium also presents adherence problems. Sodium restriction is particularly challenging for many patients because they may not recognize high-sodium foods or may be incapable of reading food labels.
Establishment and maintenance of routines are sometimes difficult for patients. One study looked at HF patient strategies for managing medication compliance, demonstrating that commitment to medication taking can be interrupted by life circumstances.
A systematic review of randomized control trials that analyzed the effects of HF self-management interventions in 857 patients found that self-management decreased all-cause HF readmissions and resulted in cost savings from $1,300 to $7,515/patient/year. Therefore, all efforts that improve HF self-management should be embraced by healthcare personnel to improve patient status and outcomes and slow the associated financial drain on patients, families, and society.
In one study of 44 HF patients, utilization of a comprehensive inpatient education program and discharge planning by a single cardiac RN educator was demonstrated to significantly reduce readmission rates, independent of medical treatment, from 44.2% to 11.4%, with a related mean total cost savings of $1,541/patient. Attendance at inpatient education sessions was associated with better self-management adoption than nonattendance in an experimental educational program of 197 HF patients, and those who didn't adopt these strategies were found to be at higher risk for readmission or death.
Development and use of a critical pathway also promoted interdisciplinary HF inpatient education and positive outcomes, as well as high performance in HF core measure compliance. These data suggest that nurse-led interdisciplinary educational interventions for all hospitalized HF patients could be developed and implemented to improve postdischarge self-management.
Organizations that participated in a quality improvement program were more likely to have better HF patient outcomes, including better quality of life and fewer ED visits/HF readmissions. Patients from these facilities were more likely to have a scale, weigh themselves daily, recognize early HF symptoms, and report early symptoms to their physicians.
Outpatient HF center participation demonstrated improved outcomes, including reduced HF readmissions. Some facilities have utilized telephone follow-up calls to assess self-care behaviors related to HF. However, results are variable, ranging from nonsignificance in quality of life to improved quality of life.
What else can be done?
Physicians should arrange for office visits within 1-week postdischarge because early follow-up is related to fewer 30-day readmissions. RNs need to assess and educate HF patients on pertinent topics such as monitoring daily routines. The nurse should ask about whether there's significant social support and if the patient has the knowledge needed to support self-management of HF. Case managers and social workers need to become intimately involved in efforts to ensure that all healthcare assistance, including entitlements, medication assistance, transportation for medical visits, and social support, are sufficient for the patient to succeed with postdischarge self-management.
The following self-care/dependent-care requisites need to be identified: Can the patient weigh in daily and record/report abnormal findings (considering vision, memory, writing ability, and availability of a telephone)? Can the patient buy, sort, and administer medications correctly, and refill medications in a timely manner? Can the patient cook and afford low-sodium food? Does the patient have the desire or ability to obtain low-sodium items? Can the patient safely increase activity and balance it with rest? Can the patient recognize subtle changes in symptoms that lead to decompensation and seek appropriate help at either a healthcare provider's office or the ED?
Nurses need to educate patients to ensure that they leave the hospital with a good understanding of how to maintain a 2-g sodium diet, record daily weight, report a 3-lb weight gain to a provider, balance activity as tolerated with rest, and recognize signs and symptoms of HF exacerbation, as well as when to call the provider's office or go directly to the ED. This type of educational approach has demonstrated positive effects as evidenced in nursing research studies.
The goal? Reduce HF readmissions
HF is a chronic and progressive disease, meaning that not all hospitalizations for HF can be prevented. There are a multitude of tactics that hospital employees can undertake in strategic efforts to assist patients with postdischarge self-management support. Utilizing such techniques can help reduce HF readmissions, associated length of stay, and financial burdens to patients and facilities. Optimizing inpatient education and assistance enhances the HF patient's ability to provide self-care and serves to enhance patient satisfaction, which can ultimately lead to improved quality of life—slowing the progression of the disease and decreasing mortality from HF.
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