Clarifying Connections: Practice Problem, Evidence, Changing Practice
Practice Problem: Lack of fully informative congestive heart failure (CHF) education to patients at discharge
Heart failure hospital readmission rates [within 30 days of discharge] are significantly impacted by patient non-compliance. In part, this facet of non-compliance is affected by inadequate discharge teaching, which should not only include information regarding dietary restrictions (i.e. low sodium and restrictive fluid intake) but should also include obtaining the patient’s euvolemic weight prior to discharge to establish a baseline for continued measurement post discharge. As such, when the patient’s weight has exceeded a determined threshold, the patient knows to notify the cardiologist for further advisement on adjustments of diuretics and potentially avoid hospital readmission. Furthermore, the dialogue of discharge education should factor in the patient’s healthcare literacy status, any language barriers, and/or any economic constraints that could impair procurement of necessary medications or facilitation of follow up appointments.
Results of Literature Review
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My literature review results yielded specific consideration points: 1) accurate recording of patient daily weight directly affects dosing and type of diuretics administered (Al-Rafae & Taylor, 2021), 2) patients with CHF are at great risk for frequent readmission due to self-care deficits (David et al., 2018) and 3) inadequate heart failure discharge teaching is statistically linked to preventable hospital readmissions (Becker et al., 2021). These points of consideration lend to a practice gap that can and should be further evaluated by an EBP QI initiative, which may lead to practice change and ultimately reducing avoidable heart failure readmissions.
Synthesis of Literature
Heart failure hospital discharge teaching involves a multi-faceted approach including the provision of exorbitant written information regarding medications, lifestyle modification and coordination of follow up appointments. Inadequate performance of this teaching could result in an avoidable readmission within 30 days of discharge and expenses that have thus far cost the American hospital system an annual $20 billion (Becker et al., 2021). Ergo, an EBP QI initiative to improve heart failure discharge teaching is worthy to conduct to implement practice change.
Proposed Practice Change
My proposed practice change is two-fold: First, inclusion of an accurate euvolemic weight – taken the day of discharge – of the patient as part of discharge teaching. This significant data will serve as a reference point for intravascular volume management once out of the immediate care of clinical staff. Patients [and nursing staff of LTAC/skilled nursing/rehabilitation facilities, if the disposition location of the patient is not their home] can then be instructed on when to notify the established cardiology provider for diuretic medication adjustments [or perhaps an office visit for IV diuretic therapy] to potentially avoid hospital readmission. Second, delivery of discharge education in a manner that is understandable to the patient. Education on dietary restrictions and lifestyle modification should be specific to the individual and relayed in clear, understandable, and non-ambiguous terms, which will aid in reinforcing compliance. For example, when educating a patient on fluid restriction – many nurses and providers will tell patients to limit their daily fluid intake to 50ounces. I have personally encountered patients who have no concept of how much volume 50ounces is. However, they are very familiar with a 2-liter bottle. So, I advise them to limit fluid intake to one 2-liter bottle (equivalent to approximately 60 ounces) for the day – and this is all inclusive of anything that would be a liquid consistency at room temperature (popsicles, ice, all drinks, etc.).
Al-Rafae, N., & Taylor, L. (2021) Daily Weight and Fluid Balance Assessment in Patients Admitted with Acute Heart Failure. Heart, 107, A113-114.
Becker, C., Zumbrunn., S., Beck., K., Vincent, A., Loretz, N., Muller, J., Amacher, S., Shaefert, R., & Hunziker, S. (2021). Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-Analysis. JAMA Network Open, 4(8), e2119346. https://doi.org/10.001/jamanetworkopen.202Links to an external site..
David, D., Howard, E., Dalton, J., & Britting, L. (2018). Self Care In Heart Failure Hospital Discharge Instructions – Differences Between Nurse Practitioner and Physician Providers. The Journal For Nurse Practitioners, 14(1), 18-25.
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