Decreasing Chronic Heart Failure Inpatient Readmissions

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The paper will provide an overview of a study done to determine if educational tools on self-management help in readmission reduction rates in people suffering from Chronic Heart failure.

Abstract

The paper analyses a study by Shaw et al. (2014), on the importance of education on self-management in patients with Chronic Heart Failure (CHF). The introduction in the paper introduces the prevalence and incidence of CHF and the importance of education on self-management. The literature review analyses the journal article information. The discussion in the paper looks at different articles and the journal to compare the ways in which the self-management tools have been efficient to help in reducing the rate of re-admission.

Introduction

Chronic heart failure is a disease that comes from heart complications such as coronary heart disease. The prevalence rate of HF in the United States is 5.7 million people. The burden is exceptionally high with people above the age of 65, wherein every 1000 people, 10 have CHF, and 7.2% of deaths are also attributed to the disease. In Medicare patients, it amounts to half of the discharges of older adults, with half of them being readmitted after six months (Shaw et al., 2014).

The condition possesses a burden to the people affected, the community, and the country's economy. This is because the condition is expensive to treat, bringing a financial burden. However, for people above 65, it has a more significant challenge as they lack or have minimal social support. They have many conditions to treat, some lack success in treatment options, and an elaborate medication list they cannot comprehend (Abbassi et al., 2018). The high readmission rate of Congestive Heart Failure patients should be addressed to decrease the rate (Horwitz & Krumholz, 2020).

There is a need to appropriately diagnose and treat patients with CHF as these conditions help improve the quality of care. Even so, most people are not aware of the disease. There is a need for education on how to self-manage the condition; this helps decrease the burden of readmission economically, emotionally, and socially. In self-management, the individual should be taught on a diet to take, check weight and amount of fluid, physical exercise, and check for extremes in drug allergies. There is a need to implement education to the family, and the patient and the family/friends may be of help to the individual in the self-management activities (Ruppar et al., 2016). The implementation of outpatient educational tools was seen to show a significant decline in the number of cases of readmission. The educational tools include dietary monitoring, weight monitoring before breakfast and after urination, adherence to drug regime, physical exercise, and the monitoring of adverse effects from medication and other causes (Moser et al., 2012). Through the various research done, there was a significant show that when one can self-manage after being given the right education, the readmission rates reduce. Also, there is a reduced number of mortality cases (Ruppar et al., 2016).

.The knowledge of reduced intake of Sodium has also been made clear by the experience on high sodium levels may increase the amount of water retained in one's body. Physical exercise benefits in HF are also different compared to other conditions that need total rest. The effect of rest on HF is seen to increase its symptoms, and this should be taught to the patients who are concerned that when they have routines of physical exercise, they could get more ill. Drug adherence is a critical aspect of self-management as it is a way to prevent readmission (Toukhsati et al., 2019). For a patient to adhere to drugs, one needs to make sure that they know why they are taking each medicine. A medication log is required for the formulation to help the patient remember when to take each drug to avoid taking the wrong drug or missing a dose. Evaluation and follow-up techniques should be implemented to measure the success rate of the self-management techniques implemented.

Literature Review

Shaw et al. (2014), analyzed the organizational changes in interventions of self-management that lead to a lower readmission rate. The study was conducted with people of ages 41-86, and 98% were males, 75% were white, 83% were Non-Hispanic, 10% smokers, and 50% were non-smokers. The study tested the Chronic Care Model in two perspectives of the clinical information systems and self-management support. The CCM shows the delivery design, decision support, the information system, links to the community, self-management support, and the health system's organization, offering the support system behind self-management tools. The training was done by 2RN's who had an education and training background essential for the people with CHF.

The education was done using educational workbooks and refrigerator magnet, which showed the critical signs of HF's early and late stages. The involvement of the patient engagement framework helped inform, engage, and empower the patient in the lifestyle, diet, and medications. The patients were taught about the changes in symptoms such as weight gain that called for a check-up and other vital signs. The workbook contained critical readings such as weight, blood pressure reading, medication, and sodium intake. The packet also contained the essential nutritional guidelines needed for a patient to control the condition effectively. Virtual Assistance services included self-monitoring, an appointment to HF specific clinics, and healthy classes. The patients were also taught about to recognize advanced symptoms concerning the Magnet. However, this happened to the intervention group only. The usual care group did not receive the Magnet or advanced education materials to help them with self-management. The study results showed that four patients in the intervention group and six patients in the usual care were readmitted within 90 days. Four patients from the representative care group and two patients from the intervention group in the emergency room (Shaw et al., 2014). The research has a limitation as it uses many males than females and this limits the information observed from the different patient characteristics.

Discussion

Studies have shown the efficiency of self-management education among HF patients to reduce the burden of readmission and mortality. Self-management education entails the educators, material for education, the patients, and family/caregivers. These are essentials when trying to implement programs for education on self-management of CHF. A plan for the intervention should also be worked out, and a follow-up plan also included. It is essential to draw an evaluation to establish if the self-care regime is working or some changes need to be made to help implement the plan. Educators also need to be taught before giving information to the people as they are the source required to enlighten the crowd. Additional information from the usual care before discharge should be introduced to the educators, especially those in the primary care centers.

Education to patients entails on the right medication, adverse symptoms that should be watched out for when a patient is taking medication, sodium intake regime, body weight measurements to check on fluid uptake, and physical activities that they should be undergoing. Diet is also an essential part of the routine, with educators teaching the patients what to eat and what to leave out. Medication adherence is also a necessary part of self-management. The educator's role is to teach the patient the importance of drug adherence to avoid being readmitted.

Some patients also go through depression due to the condition. An educator should know when the patient is in this stage to help them cope. A psychologist could be consulted to help when a patient is undergoing this phase for older patients. They may not have the ability to self-manage alone; it is the educators' responsibility to ensure that the caregivers/family understand about the condition of the family, the medication regime, physical activities they should assist in, dietary needs, the sodium uptake needed, and the importance and how to check the bodyweight to ensure that the patient is able has the right amount of fluid in their system concerning fluid retention.

The educational packet should help a person know the additional weight limit. The daily home control weight check shows for signs of hypovolemia. In this, patients should check their weight after urination and before breakfast. The patient should also use the same measuring scale they use and ensure that they have light clothes on while measuring. An increase of 1.3 kgs in two days indicates that the body is retaining fluids and a rise of 1.3-2.2 kgs in a week shows the same. When this happens, the patient could communicate to the health provider to see if the dosage of diuretics will be increased or readmission for monitoring may be ordered.

Early signs that should be noticed should also be included in the educational packet. Edema tolerance seen in instances such as swelling on the foot, fatigue, weight gain, and dyspnea for three days and fatigue for seven days may be symptoms to watch out for. The patient should also be taught how to check if the drugs have adverse effects to consult their primary caregiver. Medication adherence plays a vital role in reducing mortality and readmission of patients back to the hospital. Patients should be taught the importance of each drug they take. Medication for HF includes Diuretics, Angiotensin-Converting enzyme, Beta-Blockers, Epironolactane, and Digitalis. The educators could log where each pill is indicated, and the time when after the patient takes the medication, they tick against it. This helps in some patients not mixing the medicine and forgoing others. The log is also essential as it acts as a motivational tool each day for the patient to take the medication due to the ease of remembering which drug to take (Shaw et al., 2014).

Physical exercise regimes and rest are an essential part of self-management. The increase in knowledge of the pathophysiology of the disease is necessary. Physical exercise has benefits associated with its stable chronic dysfunction. HF is associated with accelerated symptoms and dyspnea when the body in a state of rest and stress. The amount of physical activity that a patient should perform depends on the HF grade and age. However, rest is also a necessity in useful body function as it brings about an increase in renal blood flow and improved urinary debt. Prolonged rest is not good as it also leads to the damage of skeletal muscles, worsening of HF symptoms, thromboembolism, and a decrease in tolerance towards physical exercise. Educators and primary caregivers should then implement a log of workouts that the patient should perform depending on individual characteristics.

The diet of an individual with HF is also essential in the educational packet as it entails sodium uptake, fluid restriction, and vaccination recommendations. Patients should be advised to refrain from the addition of salt in already prepared food. The avoidance of canned food and industrialized foods rich in Sodium should also be recommended against. Sodium intake should also be restricted to 2g/day for severe HF and 3-4g/day for mild or moderate HF. The importance of decreasing the uptake of Sodium is to help reduce water retention in the body. This should be taught to help patients understand why they are restricted to those levels of Sodium. Educators could also put an easy way for HF patients to measure the salt intake before adding to food while cooking it.

The amount of fluid taken in is also regulated. Patients should be advised to take up to 1.5L of fluids per day for these with severe HF. However, fluid intake restrictions can lead to thirst, which shows a person to take more fluids. The patient should regulate the amount they bring to the recommended levels to ensure they practice self-management efficiently. The avoidance of alcohol and tobacco use is highly recommended due to their adverse effects on the cardiovascular system. Alcohol reduces myocardial contractility, and this may lead to heart arrhythmias. Vaccination is also advised on annual vaccinations for Influenza as they reduce the risk of respiratory infections and disease decomposition.

The self-management skills implementation should be measured to show the success rate. Educators and implementers of self-management should get a routine to follow-up on the patients even a year after the education. This will help analyze the readmission rates in the people who had self-management implemented and also on those who neglected self-management or were not taught. Technology can help in the monitoring of people with HF. Though strategies such as telemedicine and apps essential for monitoring the weight virtually and other symptoms recorded, primary health care providers can also measure the success rate of the self-management education they have given to the client. Research opens up the scope by which people can develop new strategies to help patients in self-management. The population scope is also enlarged as different people will respond differently to diet, medication, and self-management routines.

References

1. Ruppar, T. M., Cooper, P. S., Mehr, D. R., Delgado, J. M., & Dunbar‐Jacob, J. M. (2016). Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta‐Analysis of Controlled Trials. Journal of the American Heart Association, 5(6). https://doi.org/10.1161/jaha.115.002606
2. ‌Abbasi, A., Najafi Ghezeljeh, T., & Ashghali Farahani, M. (2018). Effect of the self-management education program on people's quality of life with chronic heart failure: a randomized controlled trial. Electronic Physician, 10(7), 7028–7037. https://doi.org/10.19082/7028
3. ‌Shaw, J. D., O’Neal, D. J., Siddharthan, K., & Neugaard, B. I. (2014). Pilot Program to Improve Self-Management of Patients with Heart Failure by Redesigning Care Coordination. Nursing Research and Practice, 2014, 1–10. https://doi.org/10.1155/2014/836921
4. ‌Toukhsati, S., Jaarsma, T., Babu, A., Driscoll, A., & Hare, D. (2019). Self-Care Interventions That Reduce Hospital Readmissions in Patients With Heart Failure; Towards the Identification of Change Agents. Clinical Medicine Insights: Cardiology, 13, 117954681985685. https://doi.org/10.1177/1179546819856855
5. ‌Horwitz, L., & Krumholz, H. (2020). Heart failure self management. Uptodate.com. https://www.uptodate.com/contents/heart-failure-self-management
6. ‌Moser, D. K., Dickson, V. V., Jaarsma, T., Lee, C., Stromberg, A., & Riegel, B. (2012). Role of Self-Care in the Patient with Heart Failure. ScholarlyCommons. https://repository.upenn.edu/nrs/144/?utm_source=repository.upenn.edu%2Fnrs%2F144&utm_medium=PDF&utm_campaign=PDFCoverPages