Hospital Discharge Education for Chf

66 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 http://ccn.aacnjournals.org

mates, 54% of readmissions may bepreventable, and inadequate dis-charge planning and education orlack of patient follow-up are commonfactors in readmission.3-5 Lack ofcompliance with medications, fail-ure to follow a salt-restricted diet,and delays in seeking medical atten-tion are among the primary reasonsfor the high rate of rehospitalizationamong patients with heart failure.6

Patients who are not knowledge-able about their disease and theirmedication are at a severe disadvan-tage. In one study,7 the associationof medication adherence and knowl-edge was tested in 61 patients age50 years or older who had heartfailure. Patients knowledge of thedosage, frequency, and indicationof each of their heart failure medica-tions and patients ability to openmedication bottles, read labels, anddistinguish tablet/capsule colorswere assessed. Lower medicationadherence (P = .001) and an inabil-ity to read labels (P = .002) weresignificantly associated with anincreased number of cardiovascular-related visits to the emergencydepartment. Patients with greatermedication adherence had a mean

Sara Paul, RN, MSN, FNP

Despite advances intherapy, morbidityand mortality remainhigh in patients hos-pitalized for heart

failure. Although new approachesto improving the use of guideline-recommended evidence-basedtherapies at hospital discharge areundeniably needed,1 truly compre-hensive and competent care forpatients hospitalized with heart fail-ure requires a strong focus on edu-cation of patients and their families.

Education at discharge is a vitalcomponent of improving outcomesin heart failure. The institution of astructured system of patient andfamily education that involves amultidisciplinary team and empha-sizes medication adherence, sodiumand fluid restrictions, and recogni-tion of signs and symptoms thatindicate progression of disease maybe as important as ensuring thatpatients are prescribed appropriatemedical therapy. Specific topics ofinstruction for patients hospitalizedwith heart failure are listed in Table 1.Poor adherence to these instructionscan lead to worsening of disease andrehospitalization. According to esti-

Clinical Article

Hospital Discharge Educationfor Patients With Heart Failure:What Really Works andWhat Is the Evidence?

PRIME POINTS

Educating patientsbefore discharge promotes self-care,reduces readmissions,and helps patients spotproblems early.

Patients should beactive partners in themanagement of theirhealth.

Patients shouldlearn about their conditions and medi -cations and when toseek medical treatment.

Nurses need tounderstand the barri-ers to self-care andhelp patients overcome these barriers.

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(standard deviation) of 0.22 (0.73)visits to the emergency departmentper patient compared with patientswho were less adherent, who had1.00 (2.47) visits per patient. Over-all, greater knowledge of, skills with,and adherence to medication wereassociated with fewer visits.

Education of patients at dischargepromotes self-care, reduces readmis-sions, and helps patients identifyproblems early, increasing the chancesfor intervention and improved out-comes. In this article, I discuss theimportance of educating patientsand their families in preventingrehospitalization for heart failure. Ialso address the use of performancemeasures to improve patients out-comes and methods for promotingretention of discharge instructions.

Performance MeasuresRelated to Discharge Education for Patients With Heart Failure

Performance measures are crite-ria used by organizations to deter-mine whether an organization isfulfilling its vision and meeting itspatient-focused goals. These meas-ures are standardized to evaluatehospitals and health care systems,regardless of location, in order topromote positive outcomes in patientcare. Performance measures mayreflect medical management ofpatients, but they may also assessaspects of patient care, such as edu-cation of patients and their familiesat discharge. The latest guidelinesfor management of heart failure fromthe Heart Failure Society of America

recognize the importance of educa-tion and recommend that patientsreceive educational materials as partof the patients complete dischargeinstructions.8 These materials shouldaddress recommended activity level,diet, discharge medications, follow-up appointment, weight monitoring,and what to do if signs or symptomsworsen.2,8,9

The American College of Cardi-ology/American Heart Association(ACC/AHA) Clinical PerformanceMeasures for Adults With ChronicHeart Failure9 include the followinginpatient performance measuresfor patients with heart failure: dis-charge instructions, evaluation ofleft ventricular systolic function,angiotensin-converting enzymeinhibitor or angiotensin-receptorblocker for left ventricular systolicdysfunction, adult smoking cessationadvice/counseling, and anticoagu-lant at discharge for patients withatrial fibrillation. The guidelinesrecommend that the clinical careteam collect data and review com-pliance with these measures on aroutine basis, look for changes, andadjust practice patterns as neces-sary to improve performance. Theperformance measure of dischargeinstructions and its components areshown in Figure 1.9

The Joint Commission evaluates4 performance measures for patientswith heart failure that are similar tothose of the ACC/AHA: dischargeinstructions (HF-1), assessment ofleft ventricular function (HF-2), useof angiotensin-converting enzymeinhibitors in patients with left ven-tricular systolic dysfunction (HF-3),and smoking cessation counseling(HF-4). These Joint Commissioncore measures require that patients

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Table 1 Lifestyle changes required in the self-management of heart failureaAdopt a low-sodium diet (


with heart failure receive writteninstructions or educational materialat discharge that will adequatelyaddress all of the componentsmentioned in the guidelines.10 Theintention is that through use ofthese performance measures, thequality of cardiovascular care willbe improved.11 However, conformitywith these indicators among healthcare providers is not guaranteed.

In 1997, medical records from9 hospitals were retrospectively

reviewed to determine the percentageof patients who receive the quality ofcare indicators derived from the clini-cal practice guidelines of the Agencyfor Health Care Policy and Research.A total of 1623 hospitalizations forheart failure were reviewed; the meanfrequencies of documentation ofcounseling about medications,weight, diet, exercise, and smokingcessation were as follows:

Medications: 97% (range, 95%-98%)Weight: 6% (range, 3%-12%)

Diet: 70% (range, 58%-94%)Exercise: 61% (range, 26%-81%)Smoking cessation: 14% (range,

0%-33%)The variability of counseling

between hospitals was high, anddocumentation may not reflect whatwas actually practiced.12 The docu-mentation may or may not havereflected the extent of the counsel-ing. How the information was con-veyed and the depth of the patientsunderstanding of the information

Figure 1 American College of Cardiology/American Heart Association performance measure: discharge instructions. Abbreviations: CMS, Centers for Medicare and Medicaid Services; HF, heart failure; ICD-9-CM, International Classification of Disease, Ninth Revision, Clinical Modifi-cation; JCAHO, Joint Commission.

Reprinted with permission from ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure: A Report of the American College of Cardiol-ogy/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures)Endorsed by the Heart Failure Society of America.2005, American Heart Association, Inc.

4. Discharge InstructionsHeart failure patients discharged home with written instructions or educational material given to the patient or care giver at discharge

or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen

Numerator Heart failure patients with documentation that they or their caregivers were given written dischargeinstructions or other educational material addressing all of the following:1. Activity level2. Diet3. Discharge medications4. Follow-up appointment5. Weight monitoring6. What to do if symptoms worsen

Denominator Heart failure patients discharged home.Included populations: Discharges with an ICD-9-CM Principal Diagnosis Code for heart failure as defined in table 3 A discharge to home or home careExcluded populations: Patients less than 18 years of age

Period of assessment Hospital discharge

Sources of data Administrative data and medical records

Rationale

Education of heart failure patients and their families is critical. Failure of these patients to comply with physicians and other health careproviders instruction is sometimes a cause of HF exacerbation. A significant cause of patients failure to comply is lack of understand-ing. It is, therefore, incumbent on health care professionals to be certain that patients and their families have an understanding of thecauses of heart failure, prognosis, therapy, dietary restrictions, activity, importance of compliance, and the signs and symptoms ofrecurrent heart failure. Throrough discharge planning is associated with improved patient outcomes (11).

Reference Recommendation(s)

CMS/JCAHO Core Measure: Heart Failure, HF-1: Discharge Instructions (9).

Method of Reporting

Aggregate rate (standard error) generated from count data reported as a proportion.


were not documented. More recently,data from 81 142 admissions ofpatients with heart failure in theAcute Decompensated Heart FailureNational Registry (ADHERE) wereanalyzed to determine rates of con-formity with the 4 core performancemeasures from the Joint Commis-sion.13 The median rate of conform-ity with discharge instructions (HF-1)was only 24% (range, 0%-99%), andthe median rate of conformity withHF-4 (counseling for smoking ces-sation) was 43.2% (range, 0%-100%).A substantial gap in overall perform-ance is apparent among hospitals.The establishment of educationalinitiatives and quality improvementsystems to reduce this variabilitymay substantially improve care.

Does Compliance WithPerformance MeasuresImprove Clinical Outcomes?

The relationship between currentACC/AHA performance measuresfor patients hospitalized with heartfailure and clinical outcomes wasinvestigated in the Organized Pro-gram to Initiate Lifesaving Treatmentin Hospitalized Patients With HeartFailure (OPTIMIZE-HF), a registryand performance improvementprogram for patients hospitalizedwith heart failure. Only use of anangiotensin-converting enzymeinhibitor or an angiotensin-recep-tor blocker at discharge was associ-ated with a reduction in mortalityor rehospitalization at 60 to 90 daysafter discharge.14 Trials comparingconventional management of heartfailure with management programsthat included counseling of patientsabout diet, exercise, medications,and monitoring have shown thatdisease management programs can

reduce hospital stays and improvefunctional status.15 However, theseprograms often involve outpatientprograms, such as clinics or homevisits, that are beyond those nor-mally assessed in the ACC/AHAperformance measure on dischargeinstructions. It is unclear whetherthe discharge instruction perform-ance measure as recorded in thehospital reflects whether the patientsdid or did not receive each definedcomponent of education. Patienteducation may be documented inthe medical record even if the edu-cation was cursory and allowed littletime for the patient to absorb andretain the information.15 Conversely,many patients and their families arenot ready to learn at the time ofdiagnosis, regardless of how thoroughthe instructional session may be.Extensive education may be betterabsorbed when a patient is in a sta-ble condition and has adapted toliving with heart failure.16

In the analysis of data fromOPTIMIZE-HF, the discharge instruc-tion performance measure did nothave an effect on mortality or rehos-pitalization at 60- to 90-day follow-up.14 Fonarow et al14 concluded thatcurrent performance measuresrelated to heart failure, other thanthe prescription of an angiotensin-converting enzyme inhibitor or anangiotensin-receptor blocker at dis-charge, have little effect on patientsoutcomes shortly after discharge.Another OPTIMIZE-HF analysis17

specifically addressed education ofpatients; researchers assessed thecharacteristics of patients who didand did not receive the full set ofcomponents from the Joint Com-mission process-of-care performancemeasure (HF-1) and then analyzed

whether receipt of this measure waspredictive of other elements of dis-charge planning. Credit for the coremeasure (HF-1) was not given unlessall 6 components (activity level, diet,discharge medications, follow-upappointment, weight monitoring,and what to do if signs or symptomsworsen) were documented. Despiterecommendations that completeinstructions be given to patients withheart failure before hospital discharge,both the process intervention tools tofacilitate HF-1 and HF-1 itself wereunderused. Delivery of the full set ofHF-1 components was significantlymore likely in the 46% of patients whoreceived process improvement tools.17

Additional measures and/or bettermethods for identifying and validat-ing performance measures related toheart failure may be needed toimprove care and outcomes ofpatients with heart failure.14

Data suggest that in practice,discharge education is not empha-sized as an essential component ofoptimal care for patients with heartfailure. A retrospective review18 ofmedical records at a large, inner-cityteaching hospital of 104 patientswith heart failure showed that dis-charge counseling about medicationadherence, restricted sodium intake,and the importance of weight moni-toring was provided to only 50%,48%, and 9% of patients, respectively.The large number of patients whoare discharged without receivingeducation may represent importantmissed opportunities to decreasemorbidity and mortality.

Educational Tools and aMultidisciplinary Team

Critical pathways and in-hospitalinstructional tools may improve the

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provision and quality of dischargeeducation. The AHA Get With theGuidelines heart failure program isa hospital-based quality improve-ment program implemented in 2001to promote the use of up-to-dateguidelines for treating patients withheart disease and stroke. Currently,more than 1300 hospitals are enrolledin the program.19 A key componentis the Patient Management Tool, aWeb-based interactive assessmentand reporting system that trackstreatment and facilitates evidence-based medicine. This tool helpscaregivers manage patients care byproviding (1) drop-down remindersof current guidelines at key datapoints, (2) prescriptive medicationreminders specific to the patientsdisease, (3) printed disease-specificpatient education materials beforedischarge, and (4) automated patientdismissal notes and referringphysician letters.20 An example ofthe discharge instructions is shownin Figure 2.19 This tool includeseducation as part of the overalldischarge checklist.

Although many hospitals areadapting the tools from the Get Withthe Guidelines heart failure programinto care, the presence of tools aloneis not enough to guarantee evidence-based practices. In a study21 of howcore measures from the Joint Com-mission are applied at a universityhospital, availability of standardizedorder forms, computer dischargeinstructions, and education materi-als did not lead to improvement inscores for core measures. The scoresimproved only after the appointmentof a dedicated heart failure physicianand nurse practitioner who usedthe standardized forms, computerdischarge instructions, and the

education materials. Use of the ded-icated heart failure team led to quickand sustained improvements.21

In addition to verbal information,a combination of educational mate-rials may enhance a patients abilityto absorb information. Books,newsletters, videos, CDs, Web pages,and computer-based programs aug-ment the learning process and offerfurther opportunities for educationat patients convenience after dis-charge from the hospital. Manypatients will need repeated educationthrough follow-up telephone calls,newsletters, educational bulletins,or support groups because of thevolume of information that is givenat the time of hospital discharge.

Educational tools must be a com-ponent of multidisciplinary careprovided to heart failure patients.22

The team approach to education ofpatients improves patients outcomes.In one study,23 an intervention group(n=44) of patients received educa-tion from a cardiac nurse educator,a registered dietitian, and a physicaltherapist, along with correspondingwritten materials. These patientsreceived an initial visit, as well as afollow-up visit from the nurse edu-cator, dietitian, and physical therapistduring the patients hospitalization.Discharge planning was coordinatedwith home health nurses, who rein-forced the instructions given in thehospital. Patients in the control groupwho received usual care did nothave access to the nurse educator,did not automatically receive dietaryand physical therapy consultations,did not have routine telephone con-tact after discharge, and did notreceive home visits from nursestrained in management of heartfailure. Hospital readmission rates

were 4 times higher in the groupof patients who received usual care(n=77) than in patients in the inter-vention group. Additionally, patientsin the control group required nearly50% more skilled nursing care visitsand more than twice as many homehealth aid visits than did the patientsin the intervention group. The 6-weekcost savings for the interventiongroup was $67 804.

Barriers to LearningSuccessful management of heart

failure often requires major lifestyleadjustments, such as modificationsin diet and activities, compliancewith a complex medication regimen,and the need to assess and monitorsigns and symptoms. Despite bestefforts at education, helping patientsunderstand all of the complexitiesof their disease and therapy may bedifficult. Many patients have lowlevels of knowledge of their diseaseand lack a clear understanding ofheart failure and self-care. In a study24

of knowledge level in patients withheart failure, although two-thirdsof the patients reported receivinginformation or advice about self-carefrom health care providers, 37% ofpatients knew a little or nothing,49% knew some, and only 14%knew a lot about heart failure.Approximately 40% of the patientsdid not recognize the importance ofweighing themselves daily, and 25%did not appreciate the risk of con-suming alcohol. Although 80% of thepatients knew they should limit theamount of salt in their diet, only one-third regularly avoided salty foods.

Understanding patients barriersto learning may enable nurses totailor educational approaches accord-ingly. Simply communicating a



Figure 2 The American Heart Association Get With the Guidelines heart failure discharge tool.19

Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; CHF, congestive heart failure; CM,case manager; info, information; MD, physician; rehab, rehabilitation; RN, registered nurse.

Discharge Medications Dosage Frequency Start Date/Time

Nitroglycerin

Aspirin 81 mg

ACE-I/ARB

Beta-Blocker

Statin

Clopidogrel

Spironolactone

Pain

Exercise/Activity/Diet/Prescription Information Given: See back for health education and resourcesIf you smoke, STOP! (Smoking will make heart disease worse and may cause death.)

Booklet Given, see back Does not smoke - or - Has not smoked in more than 12 months

AMI/CHF Discharge Packet Given Home Exercise Program Instruction Provided

Drug info/food/drug interaction info provided Cardiac Rehab Information Provided

Daily Weights Instructions Given-See back Cardiac Rehab Ordered Yes No Diet __ Low Sodium, Low Cholesterol, high fiber Your Total Cholesterol: ___

Resources on back reviewed Driving Instructions Given

May Return to Work on (date) ___________________ Activity: Light activity until follow-up appointment

Follow-Up appointment:

___________ Dr.: ___________________________ Phone: ___________________________________ Date: ___________

___________ Dr.: ___________________________ Phone: ___________________________________ Date: ___________

Home Care Agency: _______________________________ Phone: ___________________________________ Date: ___________

CARDIOVASCULAR DISEASE DISCHARGE INSTRUCTIONS

MD/RN Signature _________________________________________________________________________ Date ______________

Choices Provided on ______________________________ :CM Signature ________________________________ Date __________

I have received a copy of this form and understand the instructions. Patient signature ______________________________________

NOTE: Any old, unused pills or liquid at home should be flushed down the toilet. Please discuss with your doctor any medications(including over the counter pills or liquid not ordered by the doctor) you have been taking at home if they are not listed above.

KEEP THIS FORM AND BRING IT WITH YOU TO ALL FOLLOW-UP DOCTOR APPOINTMENTS



therapeutic plan is different fromsuccessfully educating patients andtheir families. Patients and theirfamilies should be treated as partnersin learning, not as pupils. If patientsfeel engaged in the discussion andtheir learning needs are assessed,they may feel that the informationis more pertinent to their situation.Teaching sessions should not be a1-way communication session, butshould engage patients in identifyingtheir learning needs.25 Nurses whoteach patients should receive trainingto ensure that the educational infor-mation taught is consistent amongall staff members. If the informationvaries among the staff, patients andtheir families can become confused.

Hospitalized patients may beanxious about their disease and maybe concerned about their ability toperform self-care once they are home.Plenty of time should be allowed forpatients to ask questions as theydigest the new information. Paperand pencil should be available at thebedside for patients to write downquestions as they think of them.Patients and family members shouldbe given a telephone number thatthey may call to speak to a nurse ifthey have any questions or problemsafter discharge. Knowing that theywill receive follow-up home visits ortelephone calls may allay their anxi-ety and fears and allow patients toabsorb information more readily.

An articulate and fluent transla-tor should be included in teachingsessions when patients do not havecommand of the English language.The translator should be availableif a patient has questions later. Cul-tural differences may impede thelearning process. Dietary prefer-ences may be somewhat different

for patients of different cultures, andflexibility should be given to allowpatients to maintain their culturaldifferences yet remain within healthyparameters. If possible, a dietitianshould be involved to help patientsselect foods that are acceptable to thepatients palate but low in sodium.Foods such as soy sauce or tomatosalsa are high in sodium, and everyeffort should be made to find low-sodium substitutes.

Educational interventions shouldbe specifically tailored for patientsand their families and should targettheir particular barriers to learning,such as functional and cognitivelimitations, misconceptions, lowmotivation, and low self-esteem.25

The reasons for difficulty in follow-ing a prescribed regimen are multi-factorial, but possible barriers toself-care and optimal adherence mayinclude a complex medication regi-men that is confusing to the patient,cognitive impairment that makes itdifficult for the patient to rememberinstructions, or the lack of motiva-tion to follow discharge instructions.

Complex Medication Regimen

Patients with heart failure areoften discharged with complexmedication regimens.26 Despite thebest intentions of practitioners,patients understanding of the rea-son for each medication may below, and their ability to follow ther-apeutic instructions may be limited.Noncompliance can be as high as64% for medication and 22% fordiet.27 In a retrospective study28 of1031 admissions for heart failure,noncompliance with medicationsand diet led to sodium retentionand was the causative factor in 55%

of the admissions. One-third of thepatients were noncompliant withmedications, diet, or both. In a study29

of 220 patients with multiple hospi-tal admissions, the rates of noncom-pliance with medication, smokingcessation, and abstaining from alco-hol were as high as 64%, 69.5%, and71%, respectively. Compliance maybe increased by improving patientsunderstanding of the importanceof the therapy and by streamliningtherapy through the use of once-daily agents to reduce the complex-ity of pill-taking regimens.30

Cognitive ImpairmentA patients ability to understand,

remember, and apply what he or shewas taught at discharge is anotherlarge barrier. Elderly patients oftenhave comorbid conditions in addi-tion to heart failure that can make itdifficult to understand and complywith therapy. The incidence of cog-nitive impairment among patientsmore than 65 years old who haveheart failure is high compared withthe incidence in younger patients,31

indicating that education of elderlypersons is a challenge. Cognitiveimpairment may include short- orlong-term memory loss, dementia,or attention deficit. In a study ofrecall of recommendations and adher-ence to advice among patients withheart disease, Kravitz et al32 foundthat patients who did not recall theinstructions had a much greater riskof noncompliance with medicationsand diet than did patients whoremembered the instructions. Inter-estingly, patients whose physicianscounseled them about lifestylechanges and medications were sig-nificantly (P


a follow-up telephone interview.Unfortunately, even among patientswho recalled the advice, the non-compliance rate with smoking ces-sation remained high.

Cline et al33 examined the extentof noncompliance with prescribedmedication in elderly patients withheart failure and reviewed theextent to which patients recalledinformation given about it. Allpatients received standardized ver-bal and written information abouttheir medication, but only 12 (55%)could correctly name what medica-tion had been prescribed, 11 (50%)were unable to report the dosesprescribed, and 14 (64%) could notremember what time(s) the med-ication was to be taken.

To overcome memory issues, wemust ensure that all instructionsand advice verbally communicatedto patients are also provided in awritten format that patients cantake with them to share with familymembers and refer to later. Familymembers should be included in theeducational session so that they hearthe information and can reinforcethe instructions once the patient isat home. If the patients friend orfamily member who assists inpreparing the weekly medicationscannot attend a teaching session oran appointment when medicationchanges are discussed, a note explain-ing the changes should be sent homewith the patient. Even better, a tele-phone call to the person who over-sees the patients medications willprevent confusion or medicationerrors. If a patient with cognitiveimpairment does not have a familymember to assist with medications,it may be helpful to contact thepatients local pharmacist, home

health nurse, or physical therapistto clarify changes in medication. Anyhealth care professional who hasregular contact with a patient canhelp in evaluating whether the patientis taking the medications correctly.

A list of medications and whento take them should be in large print,and patients should be instructed toplace that list prominently in the areawhere daily medications are stored.Weekly pill containers with 3 com-partments per day for morning,afternoon, and night doses helppatients remember if they have takentheir medications earlier in the day.Refrigerator magnets with informa-tion about signs and symptoms ofworsening heart failure and thetelephone number that the patientshould call if those symptoms occurcan serve as easily accessible dailyreminders. Pictures of foods to avoid,such as high-sodium foods, shouldbe available for patients to keep nearthe patients grocery shopping list.Follow-up telephone calls or homevisits may help patients rememberand follow important dischargeinstructions. Charts that specify thetime of day for each medication dose,either with the use of a clock depict-ing the time or with doses scheduledaround meals, may enhance patientsability to take pills at the correcttime of day (Figure 3). Pictures ofeach pill, which can be found in manymedication books or online, can helppatients identify their medicationsand may reduce medication errors.

Lack of MotivationPatients difficulty in following

recommendations for diet, exercise,and smoking cessation may be dueto lack of motivation and/or self-control. An increase in knowledge is

not necessarily accompanied byconcomitant changes in compliancebehaviors. Poor physical capacity,fatigue, and depression and anxietyare common among patients withheart failure,25 and all these factorscan lead to lack of motivation andlow interest in learning how to per-form self-care. Ni et al24 reportedthat although most elderly patientswith heart failure confirmed theimportance of restricting sodiumintake and limiting fluid consump-tion, less than half reported alwaysavoiding salty food, and an equallylow percentage did not closely mon-itor daily weight or fluid intake. Thistype of noncompliance indicates theneed for education about the impor-tance of dietary restrictions andpotential consequences of nonad-herence. Effective communicationbetween patients, their families, andthe health care team may help mini-mize the difficulties associated withdietary restrictions.

Health care providers may thinkthat a broad statement such asremove salt from your diet orweigh yourself every day is suffi-cient education. But importantaspects of communication are leftout of instructions like these, suchas why the change is important, spe-cific details, and examples of how togo about these lifestyle changes.2

The poor taste of low-sodium foodmay also be a large barrier.34 Elicit-ing the assistance of a clinical dieti-tian for strategies that help patientsand caregivers find special food items,plan menus, adjust recipes, andalter the preparation of food can beof great benefit.2,35 Helping a patientplan meals and prepare a grocerylist with appropriate low-sodiumfoods will offer real-life ideas and


suggestions. Cookbooks and Websites with low-sodium recipes can behelpful to patients and their spousesas they plan meals (Table 2). Lists offoods to avoid, foods to enjoy inmoderation, and foods that arewithin dietary guidelines should bereadily available for patients, alongwith lists of substitutes or alterna-tives to high-sodium foods.

Although smoking can contributeto increased risk for multiple hospi-tal admissions, most patients lackmotivation to stop smoking ciga-rettes.29 Despite medical counselingand awareness that smoking inducessigns and symptoms of heart failure,patients who have been hospitalizedoften continue to smoke. Althoughsmokers may be instructed to quit,they may not be provided with theproper counseling or referral to aprogram or technique that would

assist them.36 Education and coun-seling sessions to promote behaviorchange, referral to smoking cessationprograms, and recommendations touse nicotine replacement substancesmay be key to helping patients withnicotine addiction. Medicationsthat promote smoking cessation,such as bupropion or varenicline,should be used with extreme caution,and patientsshould beclosely moni-tored duringtherapy.

Similartechniquesshould be usedin patients whoare at risk forcontinuing toconsume alcoholafter discharge.

Results of studies24,37 on alcohol useamong patients with heart failureindicate that 25% to 40% of patientswith heart failure do not understandthe risks of alcohol consumption.Efforts to educate patients about thedetrimental effects of alcohol oncardiac function should be reinforced,and resources should be providedthat can facilitate alcohol-withdrawal


Figure 3 Patient medication chart with clock.

Patients name:

PATIENT MEDICATION CHARTHeart Failure Clinic

Date Medication Dosage

Table 2 Web sites offering low sodium recipes and food suggestions

www.lowsaltfoods.com

www.alsosalt.com/lowsodiumfoods.html

http://yourtotalhealth.ivillage.com/hungry-girl-low-sodium-food.html

www.dinewise.com/low_sodium

http://www.americanheart.org/presenter.jhtml?identifier=572

www.hfsa.org/pdf/module2.pdf

http://www.hy-vee.com/health/health.asp

www.drugs.com/cg/2-gram-sodium-diet.html



efforts. Support group therapy andalcohol cessation programs may offersupport to patients who find it diffi-cult to stop consuming alcohol.

Motivation for making behaviorallifestyle changes may be low inpatients who are not ready to com-mit to making those changes. Despiteeducation on lifestyle changes thatare necessary when living with heartfailure, many patients are not readyto learn how to manage their illness.Some patients are more preparedthan others to hear the informationand make the appropriate lifestylechanges. For that reason, it is impor-tant to determine each patientslevel of readiness to make lifestylechanges and then individualize theeducational sessions to the patientslevel of readiness.38,39 For instance, ifa patient states that he or she doesnot wish to follow a low-sodiumdiet, simply handing the patientwritten information on that topicmay have limited benefit. However,exploring patients dietary prefer-ences with them and tailoring recipesand spice suggestions may offerappealing ideas to patients. If apatient enjoys foods cooked withgarlic salt, perhaps a combinationof garlic powder and onion powderwill be pleasing to the patient.Patients should be encouraged toexperiment with low-sodium spicesthat suit their personal tastes.

Methods of DischargeInstruction

The methods and delivery ofpatient education are varied andmay be important to outcomes.Education of patients consists of 5steps, beginning with assessmentof a patients knowledge, learningabilities, learning styles, cognitive

level, and motivation.25 Next, thepatients learning needs and barriersto learning must be determined. Thethird step includes discussion withthe patient to plan the educationalintervention and set goals. In thefourth step, the education and infor-mation is delivered to the patientand the patients family as planned.The last step includes evaluation ofthe learning process. Strategies thatfit with the patients learning styles,cognitive level, and motivation byusing tailored interventions offer adirected way to enhance complianceamong patients.6,7,23,25-27,29,30,34,40-45 Prac-tical ideas for improving patientsadherence are listed in Table 3.Nurses are crucial to the success ofeducation and can increase theprobability of optimal dischargeinstruction and better outcomes byusing better education strategies.23

Written MaterialsPatients with heart failure recog-

nize the importance of dischargeeducation. When asked about whatinformation is important, patientsranked information on medicationand signs and symptoms as mostimportant, followed by general edu-cation about heart failure, risk factors,prognosis, activity, psychologicalfactors, and diet.46-48 The method ofteaching patients varies from patientto patient, depending on multiplefactors. Patients educational leveldictates their ability to comprehendwritten information, and poorvisual acuity limits the benefit ofwritten materials. Language barriersmust be considered in nonEnglish-speaking communities. All printedmaterial must be written at an appro-priate reading level that will meetthe needs of a wide variety of patients.

Researchers in one study49 showedthat an educational interventionincluding written materials specifi-cally directed at patients with lowliteracy (less than ninth-grade liter-acy level) and supportive phone callswas associated with improvementsin self-care behaviors and signs andsymptoms related to heart failure.

One-on-One SessionsOne-on-one sessions between a

nurse or multidisciplinary teammember and a patient are an impor-tant component of education at dis-charge. In a trial50 of 223 patientswith heart failure, researchers com-pared the effects of a 1-hour, one-on-one teaching session with a trainednurse educator with the effects ofthe standard discharge teachingdone by the staff. Patients in theeducation group also received a copyof the treatment guidelines for heartfailure written in nonmedical, patient-friendly language. Patients receivingthe educational intervention had a35% lower risk of rehospitalizationor death. The intervention patientsalso reported increased self-carepractices. Compared with controls,they were more likely to weighthemselves daily (66% of interventionpatients vs 51% of controls, P=.02),follow a sodium-restricted diet (32%vs 20%, P = .05), and stop smoking(97% vs 90%, P = .03).50

A prospective, randomized trial51

was conducted to determine the effectof a formal education and supportintervention on 1-year readmissionor mortality and costs of care forpatients hospitalized with heart fail-ure. The intervention consisted ofan experienced cardiac nurse con-ducting an hour-long session cover-ing each patients knowledge of the



Table 3 Key strategies for providers and patients for improving education and involvement/adherence of patientsStrategy

Provider led

Nurse- or pharmacist-led disease management interventions

In-hospital initiation of medication

Improvement in communication between provider and patient about medication

Reduction in the complexity ofdrug regimens

Avoidance of medications with known adverse effects

Discussion of adherence during normal follow-up care

Heightened awareness of the possibility of poor adherence

Awareness of limitations: vision, hearing, mobility, and cognition(memory)

Awareness of low motivation (evaluation of fatigue and depression) and low self-esteem

Use of multiple educational materials

Use of multidisciplinary involvement

Patient led

Active participation in disease management

Practical implementation

Initiate or increase current involvementin a multidisciplinary program

Assess patients knowledge of medicationsbefore discharge

Provide prescriptions for medications atdischarge

Confirm that patient has been fullyinformed about medication before dis-charge

Provide written educational material

Consider once-daily therapy and/or useof polypharmacy if appropriate

Provide patient with a list of possibleadverse effects from medications;include discussion of sexual dysfunc-tion as a potential adverse effect

Confirm that patient has been fullyinformed about medication at follow-up

Note patient-specific barriers or specialcircumstances

Tailor education method and/or materialto the individual patients needs or limitations

Provide more context about why thepatients heart failure plan is important

Encourage treatment of fatigue anddepression

Provide written material, brochures,booklets, newsletters, videos, CDs,and Web-based programs to increasepatients exposure to material aboutheart failure

Include dietitian, respiratory therapist,physical therapist, pharmacist, andsocial worker in discussions

Advise patients to write down questionsin order to remember them and askwhen the physician or nurse is present

Suggest that patients attend supportgroups or teaching sessions, read allliterature that is provided, and watchall CDs or videos

Evidence or rationale supporting strategy

Readmission rates for heart failure significantlydecreased when a cardiac nurse educator was used tocoordinate an inpatient heart failure education programwith comprehensive discharge planning23

90 days after discharge, multidisciplinary interventionreduced all-cause admissions by 44% compared withusual care; heart failure admissions decreased by 56%40

At 60 days, 91.2% of patients started on -blockersbefore discharge remained on therapy, compared with73.4% who started taking the drugs after discharge41

Improved communication with patients with heart failurebefore discharge resulted in a 16% reduction in mor-tality, 14% decrease in readmissions, and 31%decrease in heart failurerelated rehospitalization, with1 life saved for 34 patients treated42

Patients on once-daily therapy had significantly greateradherence than did patients on twice-daily therapy43

Combination medications can increase adherence44

Adverse effects can decrease quality of life and preventpatients from adhering to treatment with someagents30

In 39% of encounters, providers did not ask patientsabout the medications patients are taking45

Education level, insurance, socioeconomic status,advanced age, cognitive impairment, and depressionmay be predictive of poor adherence30

Use of larger text and pictures, a mild exercise plan,slower teaching pace, increased repetition of informa-tion, and involvement of family can lessen the impactof patients limitations25

A nonthreatening climate, positive feedback, and a trust-ing relationship between health care provider andpatient can improve a patients self-esteem25

Patients with heart failure are often discharged withcomplex treatment regimens26

A team approach to patient education can reduce hospitalreadmission rates and costs22

Lack of adherence to medications, failure to follow asalt-restricted diet, and delays in seeking medicalattention are primary reasons for the high rate ofrehospitalization among patients with heart failure6

Continued



illness, the relation between medica-tions and illness, the relationshipbetween health behaviors and ill-ness, early signs and symptoms ofworsening heart failure, and whenand where to obtain assistance.Patients understanding of the top-ics was assessed and reviewed toprovide information about gaps inpatients knowledge for the nurse toaddress. In subsequent follow-upsessions (by telemonitoring), thenurse reviewed knowledge andprovided support for patients toreinforce the initial educationalfoundation, theoretically byempowering patients and offeringstrategies to improve adherence.The intervention was associatedwith a 39% decrease in the totalnumber of readmissions.51

In another study,52 179 patientswith heart failure were randomizedeither to usual care or to a nurseeducation initiative (consisting ofintensive, systematic, and plannededucation by a study nurse aboutthe consequences of heart failure in

daily life) both in the hospital and 1week after discharge. In addition toevidence-based education such asrecognition of warning signs andsymptoms of worsening heart fail-ure, problems of individual patientssuch as social interaction, sexualfunction, and limited access to thegeneral practitioner were discussed.During the hospital stay, the studynurse assessed each patients needs,provided education and support tothe patient (and the patients fam-ily), gave the patient a card listingthe warning signs and symptoms,and discussed discharge. Within 1week after discharge, the studynurse telephoned the patient toassess potential problems and rein-forced and continued education aswarranted. One month after dis-charge, patients from the interven-tion group reported complying with14 of the 19 self-care behaviors, vs12 behaviors for the control group.The increase in self-care behaviorfrom baseline to 9 months was sig-nificant in the intervention group

(t=4.9, P

and dietician plus 2 additional ses-sions focused on enhancing familysupport and patients choice throughcommunication and empathy. Self-reported dietary sodium intake and24-hour urinary levels of sodium, areflection of dietary sodium intake,were measured at baseline and 3months after the intervention.

Both groups had decreases indietary sodium intake and sodiumlevel in the urine at 3 months; how-ever, the group with the additional2 sessions that focused on familysupport had greater decreases in thelevels of sodium in the urine (mean[standard deviation], 3438 [1205] mgdecreased to 2612 [1255] mg in theintervention group vs 2945 [1606] mgdecreased to 2932 [1747] mg in thecontrol group) and had a greater per-centage of those with 15% decreasesin levels of sodium in the urine (67.9%of intervention patients vs 40.7% ofcontrol patients, P=.04).

MotivationA motivational intervention is

one that increases the likelihood ofa person choosing, continuing, andcompleting a change strategy. Abehavioral management interven-tion was designed to augment usualcare and to help patients with heartfailure establish healthier behaviorsto improve their quality of life.54

Two advanced practice nursesfacilitated the intervention, whichincluded group classes and individ-ual follow-up with telephone calls.The intervention was evaluated byreceiving feedback from the partici-pants about their satisfaction andanecdotal information from the classleaders. Patients reported high satis-faction with the intervention. Whenmotivation was defined as choosing,

continuing, and completing a behav-ioral change, the intervention waspartially successful; patients wereable to choose and begin a changestrategy but did not follow throughin continuing and completing thestrategies. Readiness to change behav-ior and perceived control should beconsidered for future studies toexamine how these factors influencelearning, motivation, and behavioralchange. Research with a motivationalmodel may facilitate behavioralchange and improve the quality oflife of patients with heart failure.

Education of Patients After Discharge

Follow-up after hospitalizationcan reinforce the education that wasdelivered at discharge. In a study55 ofhome-based care after discharge, theintervention involved a nurse visit-ing the patient once at home afterdischarge to teach the patient aboutheart failure and the medications. Areduction in heart failure events (38vs 51; P=.04) and unplanned read-missions (68 vs 118; P=.03) was seenin those patients receiving the follow-up visit at home compared with thecontrol group.55 In a study56 of 106patients assigned to either follow-upat a nurse-led heart failure clinic orusual care, fewer patients in theintervention group than in the con-trol group died or had to be admittedto the hospital after 12 months (29vs 40; P=.03). All patients answereda questionnaire after 3 and 12 monthsto evaluate their self-care behaviors,and the intervention group scoredsignificantly higher than the controlgroup did (P=.02 after 3 monthsand P=.01 after 12 months).56

In another study,57 researchersassessed the long-term effectiveness

of a disease management programthat combined discharge planning,education, optimization of therapy,improved communication, earlyattention to signs and symptoms,and intensive follow-up. After 2years, all-cause death and hospitaladmissions for heart failure were36% lower in the intervention groupthan in the usual-care group. Com-pared with baseline, patients in theintervention group reported signifi-cant improvements in functionalstatus, quality of life, and rate ofprescription of -blockers.

Telephone monitoring is a pos-sible tool to reinforce educationand assess patients status. Remotetitration of the dose of -blockercarvedilol by advanced practicenurses was studied in patients withheart failure.58 Before therapy, thenurses instructed patients about theside effects of -blockers, how totake a pulse, and monitoring weight.Three times a week, patients reportedtheir weights, vital signs, and symp-toms to the nurses by phone. Theadvanced practice nurses counseled,educated, and reminded patients toincrease the dose of carvedilol every2 weeks until the target dose wasreached. As a result of this interven-tion, 96% of patients reached a ther-apeutic dose (6.25 mg twice daily),and 71% of patients reached targetdoses of 25 mg twice weekly inapproximately 8 weeks. No hospital-izations for heart failure occurredduring this period.58 Another study59

included 14 randomized controlledtrials (4264 patients) of remotemonitoring (telemonitoring and/orstructured telephone support) todetermine if such monitoringimproved outcomes in patients withheart failure. Remote monitoring



programs reduced the rates of hos-pital admissions related to heartfailure by 21% and the rate of all-cause mortality by 20%. New tech-nologies such as telemonitoring canbe helpful tools to improve educa-tion but should be used as an addi-tion to a comprehensive educationaldischarge program.

Comprehensive ApproachAlthough they may have been

focused on a single tactical method,most of the studies mentionedinvestigated the value of a compre-hensive educational program thatincluded a combination of inpatientand outpatient education. The morecomprehensive an educational strat-egy is, the better. For instance, inone study40 patients with heart fail-ure were randomized to receive eitherusual care or a nurse-directed, multi-disciplinary intervention thatincluded a review of patients condi-tions and their medications, homevisits, dietary advice, and telephonecalls. At follow-up 90 days afterdischarge, the multidisciplinaryintervention had reduced all-causeadmissions by 44% (P = .02) com-pared with usual care, and admis-sions for heart failure were reducedby 56% (P = .04).

In a study23 of the potential ben-efits of comprehensive managementof elderly patients with heart failure,the intervention consisted of an

experienced cardiac nurse educatorwho coordinated a targeted educationprogram for inpatients with heartfailure coupled with comprehensivedischarge planning and immediateoutpatient reinforcement through acoordinated nurse-managed homehealth care program. After 30 to 60days, the readmission rate for heartfailure in the usual-care group was 6times the rate in the interventiongroup. After 6 months, the readmis-sion rate in the usual-care groupwas nearly 4 times the rate in theintervention group (44.2% vs 11.4%;P=.01).

In another study60 of 165 hospi-talized patients with heart failurewho were randomized to either acomprehensive nurse interventionor usual care, the nurse interventionincluded educating patients aboutthe disease and its treatment, includ-ing training in how to adjust dosagesof diuretics, as well as home visits,telephone contact, extensive monitor-ing of each patient, and up-titrationof medication. Patients in the nurseintervention group had fewer all-cause admissions than did patientsin the control group (86 vs 114, P =.02), had fewer admissions for heartfailure (19 vs 45, P

Financial DisclosuresNone reported.

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Sara Pauland What Is the Evidence?Hospital Discharge Education for Patients With Heart Failure: What Really Works

Published online http://www.cconline.org 2008 American Association of Critical-Care Nurses

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