11 - Discharge Planning for Heart Failure in the Short Stay Unit

Editors: Peacock, W. Frank

Title: Short Stay Management of Heart Failure, 1st Edition

Copyright ©2006 Lippincott Williams & Wilkins

> Table of Contents > 11 - Discharge Planning for Heart Failure in the Short Stay Unit

11

Discharge Planning for Heart Failure in the Short Stay Unit

Ginger A. Conway

Scope of the Problem

Heart failure is the cause of nearly 1 million hospitalizations annually.1,2,3,4 and 5 It is the most common discharge diagnosis among individuals aged 65 years and older, accounting for more than 640,000 discharges per year.4,5,6,7,8,9 and 10 Readmissions have increased since the advent of the Medicare prospective payment system.10 The 90-day readmission rates for individuals aged 70 years and older is between 40% and 60%.2,11

Emergency Department Treatment of Patients with Heart Failure

Patients present to the emergency department (ED) expecting relief of their symptoms of heart failure. These patients are evaluated and treated and are then discharged to the outpatient setting or admitted to the hospital as necessary.12 As many as 80% of those who present have previously been diagnosed with heart failure.13 Many of these individuals can be successfully treated in the ED observation unit. This is a cost-saving approach but adds to the responsibility of the ED staff to provide comprehensive discharge planning.13 Failure to meet this responsibility will result in repeated admissions to either the ED or the hospital. For those patients who go on to be admitted to the hospital, the assessment of discharge needs and the plan to meet these needs must begin in the ED.

What is Discharge Planning?

Discharge planning is a process of evaluation of the patient's needs both during the admission and after discharge. It begins at the time of admission and must be re-evaluated and adjusted as needed several times during

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the hospital stay.11 The process involves an assessment of the precipitating factors resulting in the current admission, educational needs, and postdischarge care.11,14 Discharge planning should involve the patient, all members of the health care team, the family, and any other caregivers with frequent collaboration.11,14,15 The discharge planning process and the development of the plan should be documented in the patient's medical record.14 The final plan should be communicated to the outpatient health care team, including the patient's primary care physician, because many readmissions occur due to the lack of communication between the pre- and postdischarge health care teams.10,14,16

A comprehensive, well-executed discharge planning process can prevent unnecessary delays in discharge and ensure that adequate support is available in the outpatient environment.14,15 Effective discharge planning is necessary to decrease readmissions and is particularly beneficial for the elderly.14,15 Inadequate discharge planning is linked to early unplanned readmissions.17 Evidence of an effective discharge plan occurs when subsequent readmissions are not a result of the patient's or caregiver's misunderstanding of medications, diet, or exercise instructions.16 The readmission also must not be related to lack of access to prescribed medications or treatments as a result of functional or financial limitations or psychosocial problems.16

Who is at Risk for Readmission?

Individuals who are at an increased risk for readmission need special attention during the discharge assessment and planning. Readmission rates are extremely high among all individuals with heart failure, with approximately 20% readmitted within 1 month of discharge and 50% within 6 months.3,18,19 and 20 However, as many as 50% of readmissions might be prevented with comprehensive discharge planning and after-discharge follow-up.11,21,22 Inadequate patient education and nonadherence to the medical plan may account for as many as 40% of the readmissions.23

Multiple factors have been associated with an increased risk for readmission. The elderly are at particularly increased risk, especially without adequate discharge planning.21,24 They are often ill-prepared to make the necessary lifestyle changes that can improve outcomes.24 All ages are at increased risk of readmission if they are inadequately prepared as a result of insufficient education and support prior to and after discharge.21 Several physiologic risk factors have been identified (Table 11-1). When present, these risk factors indicate a greater chance that the patient will be readmitted to the hospital for care. Patients with these risk factors need increased attention to their discharge readiness.

Other contributing factors have to do with the patient's self-care measures and the ability to make the necessary lifestyle adjustments. Many patients fail to adhere to the medical plan due to lack of confidence

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that it is necessary or will help.25 Many simply do not understand.25 For instance, few patients have the knowledge of how to follow a low-sodium diet.26 Noncompliance with medications and diet can lead to worsening symptoms and subsequent readmissions.27,28 Butler et al.20 reported that nearly one third of those discharged on an angiotensin-converting enzyme inhibitor (ACEI) stop taking them within 1 year. Delays in seeking medical care can also result in unnecessary readmissions.28

TABLE 11-1 Physiologic Risk Factors for Readmission4,7,9,24,36,37

Age 70 years or more
Ejection fraction <35%
Ischemic etiology of heart failure
History of renal failure
Diabetes mellitus
Prior hospitalization in past 6 months
Previous admission with length of stay greater than 7 days32
Edema at discharge
Weight loss of less than 3 kg
Serum creatinine 2.0 mg/dL or greater
Systolic blood pressure >180 mm Hg
Diastolic blood pressure >100 mg Hg
Lower serum sodium

Nonadherence may result from conditions that are beyond the patient's control, such as cognitive impairments that may affect abilities to learn and comply. Forgetfulness or lack of interest and noncompliance with routine follow-up also contribute to readmissions.27 The patient who is depressed is more likely to be readmitted.25,27 The financial needs of the patient must be assessed.11 The inability to pay for medications can negatively influence adherence. Many individuals have no prescription coverage, especially those older than 65 years who have Medicare as their sole source of insurance.29 These individuals must pay out of pocket for their medications.29 Hussey et al.29 evaluated the charts of 138 patients with heart failure to determine chronic medications. The average number of medications taken by patients was 10.5. The number of medications increased as the severity of symptoms increased, and the mean monthly expenditure was $438.33.

The home environment can also have an effect. It is essential for the nurse to assess the level of involvement the family and outpatient support team are capable of and are willing to provide. The lack of adequate support at home can increase the likelihood of readmissions.16,25

Is the Patient Ready for Discharge?

It is essential that the patient and the support team be adequately prepared for discharge. Kee and Borchers16 reported that 40% to 59% of

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admissions could be prevented with better assessment of readiness for discharge and adherence to guideline-based care. There are four areas that require assessment to determine discharge readiness. They are the physical condition of the patient, the medical plan, the patient's ability to comply, and the adequacy of support in the outpatient environment.

TABLE 11-2 Physical Assessment11,13

Hemodynamic stability Systolic BP > 80 mm Hg
Heart rate < 100 beats/min
Minimal orthostatic changes in BP
Stable vital signs
Oxygen saturation >90%
Cardiac rhythm Stable
No new significant arrhythmias
No evidence ischemia
Renal function Adequate urine output
Electrolytes (within normal limits)
Stable creatinine and BUN
BP, blood pressure; BUN, blood urea nitrogen.

The physical examination needs to center around symptom improvement and hemodynamic stability, mobility, and renal function.11,13 Patients should meet these physical parameters prior to discharge. Table 11-2 provides a list of parameters to be assessed. Also, patients who were ambulatory prior to admission should be able to ambulate without limiting orthostasis.

Medications need to be evaluated and adjusted prior to discharge. The preadmission medical plan should be reviewed for opportunities for improvement. One must try to determine if the admission was linked to a deficiency in the preadmission medication regimen. Lack of adherence to guideline-based care can increase readmissions. It is essential that the discharge plan include the prescription of medications that have strong evidence of improving outcomes and avoid medications that have a negative impact on outcomes. Table 11-3 lists some of the basic medication guidelines for chronic systolic heart failure. It is important not only that the patient be on the correct medications but also that the doses be optimized.27 Butler et al.20 reported that nearly half of heart failure patients are discharged from the hospital without a prescription of an ACEI. The medical treatment used to improve the patient's symptoms must be considered when deciding on the discharge medication plan.11 The patient should also be made aware that the medical plan will need modifications after discharge.

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TABLE 11-3 Guidelines for Medications for Heart Failure Patients with Decreased Ejection Fraction38

Class I
ACEI For all patients with current or prior symptoms Level A
ARB For those who are ACEI intolerant Level A
Diuretics For those with symptoms of fluid retention Level C
Beta-blockersa For stable patients Level A
Aldosterone antagonist For those with moderate to severe heart failure Level B
Hydralazine and nitrate For those on ACEIs and beta-blockers who have persistent symptoms Level A
Class II
Digoxin For those with persistent symptoms despite being on Level A medications Level B
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker. Class 1: Conditions for which there is evidence and/or general agreement that a given therapy is beneficial, useful, and/or effective. Class II: Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a therapy. Level A: Data are derived from multiple randomized clinical trials or meta-analyses. Level B: Data are derived from a single randomized trial, or nonrandomized studies. Level C: Consensus opinion of experts, case studies, or standard of care.
aApproved beta-blockers for heart failure (bisoprolol, carvedilol, and sustained-release metoprolol succinate).

Is there Adequate Support after Discharge?

Time should be spent assessing the support needs of the patient after discharge. Lack of emotional support places the patient at greater risk for readmission.25 The patient's caregivers should be involved in the assessment of needs and development of the plan.14,25 Areas to be assessed include the general health status of the patient including the preadmission functional status and the needs for health services prior to admission.11,14 The perceived needs from the caregiver's and the patient's points of view must be reviewed.14 The patient, caregiver, and medical team should work together to establish goals for the patient's discharge, and a plan to meet the needs of the patient should be implemented. The postdischarge plan should include the timing and frequency of office visits and all necessary referrals to outpatient support services, such as home health care and a disease management program.11,13

Education Needs to Decrease Risks of Readmission

The evaluation of the patient's preadmission health care behaviors including medication and dietary compliance should begin at the time of admission.11,30

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Lack of knowledge about diet and medications is multifactorial and increases the risk of readmissions.28,31 The resulting medication and dietary nonadherence leads to 48% to 50% of heart failure readmissions.7,13,28,32 Medication adherence data indicate that 25% of patients skip medications.31,32 Alarmingly, 38% of patients with heart failure report thinking they should drink large quantities of fluids and less than 50% indicate they avoid salty foods.31

Educational needs are unique to each individual, and the process of educating the patient should begin at the time of admission. The nurse must assess the patient's readiness to change. Potential triggers to change health care behavior include the patient's realization of the importance of the change as well as his or her energy level, physical condition, and current stressors.33 The stress of the current admission for the symptoms of acute decompensated heart failure can limit the patient's ability to change. The desire may be there, but the ability may be lacking. It is essential that the nurse recognize the patient's readiness to change and adapt his or her expectations accordingly. The process of becoming ready to change will continue into the outpatient setting.33

One approach to successful education is a patient-centered approach that focuses on the patient's perceived needs.30 Anthony and Hudson-Barr30 reported that the patient's perceived educational needs do not necessarily match the needs identified by the health care team. Patients and providers agree on the importance of education about medications and side effects, but patients place greater preference on information regarding resumption of daily activities than do the health care providers.30 The patient's perceived needs must be viewed as a priority and must be met for the patient to feel adequately prepared for discharge. Patients are also interested in learning about how to monitor their symptoms and progress as well as when and how to obtain assistance.15 Delays in seeking care can contribute to readmissions.28 They should also be taught about daily weights and how their symptoms relate to their self-care behaviors.25 Being cognizant of the patient's self-identified needs and incorporating them in discharge planning may improve readiness for discharge.30

Patients prefer individualized patient-based instructions on new medications to the instructions they receive from their pharmacies. This is especially true among older patients. Suggestions for patient-centered educational tools included larger print, a schedule for taking the medications that is individualized to the specific patient's needs, and the purpose and possible side effects of the medication.25,34 Education can ensure that the patient will get his or her prescriptions filled and will not stop taking their medications prematurely.35 Use of prepared discharge materials on medications, lifestyle modifications, and symptom assessment can facilitate complete discharge instructions with less time.30

The education plan and progress need to be communicated with the patient's in-patient health care providers as well as the outpatient health care team.14 The patient's caregivers and other outpatient support services

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need to be informed of the educational plan as well.14 This should all be documented in the medical record. This documentation should include the patient's individual needs and progress as well as the outpatient caregiver's ability to follow through with the plan.14 This plan should be continued in the outpatient setting. Patient education is a matter of standard of care, including specific elements on self-care behaviors, and has been identified as a quality indicator of comprehensive discharge education.26

Quality patient education not only is in the best interest of the patient but also has been mandated by the federal government. It is a required part of hospital discharge education and is now one of the core measures by which hospitals are evaluated.34 There are many topics to review with the patient and the family. A preplanned educational program will prevent omissions in the patient's education. Table 11-4 provides a list of the most common topics to be reviewed.

TABLE 11-4 Topics of Discussion with Patient27

Disease process Causes of heart failure and admissions
Why symptoms occur
Self-care behaviors Sodium and fluid restrictions
Daily weight
Symptom monitoring
How and when to call for help
Avoid smoking
Avoid alcohol
Medications Purpose
Importance of adherence
When to take
Dose
Side effects
Activity How to assess tolerance
Energy conservation techniques
Symptom assessment Shortness of breath
Orthopnea
Paroxysmal nocturnal dyspnea
Cough
Nausea
Abdominal bloating
Early satiety
Edema

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Discussion

Several studies have been published on the effects of a comprehensive discharge and follow-up plan for the hospitalized patient with heart failure. They have included interventions such as the use of specialty trained nurses, early intervention, and outpatient follow-up. Kleinpell and Gawlinski19 reported that with the use of disease-specific discharge forms for heart failure and the use of advance practice nurses (APNs) in the in-patient setting they were able to significantly improve adherence to evidence-based guidelines and core measures including comprehensive discharge teaching.19

Klienpell15 began discharge assessment and planning in the intensive care unit (ICU). Early assessment of discharge needs allowed for adequate time to plan for the home care needs, thus preventing delays at the time of discharge. They used the Discharge Planning Questionnaire (DPQ), which is a 51-item assessment of the patient's perceived needs after discharge. The patient was then asked to complete a Discharge Adequacy Rating Form after discharge to provide feedback to the investigators on the discharge planning. Their results indicated that beginning the discharge plan in the ICU was effective. The patients felt that the discharge planning was more comprehensive and that they were better prepared for their discharge. Specifically, they felt more confident about their knowledge of the medications and their ability to monitor their symptoms. However, on assessment 2 weeks after discharge, many elders did not remember the purpose and side effects of their medications,15 thus reinforcing the need for repeated instructions in the outpatient setting. One additional advantage of postdischarge telephone follow-up may be that it provides an opportunity to assess for early warning signs of trouble.15

Schneider et al.35 reported that the effectiveness of the verbal presentations, print material, problem-solving discussions during discharge planning, and medication instructions can decrease the likelihood of readmissions. Their efforts resulted in a statistically significant reduction in readmissions during a period up to 31 days postdischarge.35

Others have used alternative methods of discharge planning. Naylor et al.14 reported the benefits of having a nurse available by telephone from the time of admission, through the hospitalization and continuing on for 2 weeks after the patient's discharge from the hospital. The nurse was available for questions related to the discharge plan from the family, patient, caregivers, and health care team. Other plans for telephone follow-up include making at least two phone calls to the patient. The first occurs within 24 to 48 hours of discharge and the second between 7 and 10 days. The purpose of these calls was to assess the patient's condition, answer any questions, and reinforce the discharge instructions.14

Koelling et al.26 evaluated a 1-hour educational session provided by a nurse educator prior to discharge. The nurse provided written discharge information on medications, food and drug interactions, and side effects.

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Other topics reviewed included dietary and fluid restrictions and common heart failure symptoms. Self-care behaviors such as daily weights, symptom monitoring, and when and how to call for help were also reviewed. The rationale for all the instructions was discussed.26

Conclusion

The ED short stay unit is the appropriate place to begin the evaluation of discharge needs and start the development of the discharge plan for all patients regardless of the planned disposition after the ED. Those who are going to be released from the ED back to their outpatient setting need comprehensive discharge planning. Assessments and interventions including education, individualized medication instruction and scheduling, dietary counseling, and outpatient care coordination that have been used in the in-patient setting may improve outcomes if implemented in the ED.

A variety of methods of postdischarge support have been evaluated. Specific interventions are often difficult to evaluate because of the multi-disciplinary multiple-intervention approach in most programs. However, the evidence supports the need for a coordinated effort to prepare patients for discharge, beginning at the time of admission, with frequent evaluations. Appropriate individualized postdischarge care can have a positive impact on outcomes.

More research is needed to determine which interventions will yield the greatest benefit for the patient in this time of shorter and shorter stays for individuals seeking acute interventions for their heart failure symptoms.

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