Assessment
When I did clinical at ICU, I interacted with several patients who were admitted for congestive heart failure, and almost all of them were readmitted for a similar history of symptoms. My patient R was readmitted to an A hospital’s ICU due to heart failure (HF) and aortic valve regurgitation. After discharge, his condition had worsened due to a lack of compliance for lifestyle changes and follow-ups. The patient’s primary language is Spanish, and he barely speaks English.
I realized that there was no translator to help communicate with this patient. I also realized he had a limited understanding of his health condition and needed some lifestyle changes, self-care instructions, and compliance with medication regimens. I realized that a Spanish translator nurse would have been effective in explaining the health issues to the patient so that he could engage in appropriate self-care regimes for improved health outcomes. I think the behavior was adaptive and could have been resolved with appropriate health care techniques and interventions employed by nurses working with CHF patients.
Literature Review
Heart Failure (HF) is a primary health problem affecting millions of Americans and costing billions of dollars annually (Dennison et al., 2011). Visits to emergency rooms and rehospitalization for symptoms of HF make HF the most expensive heart disease in the United States. Hospital readmission is common among heart failure patients (Silow-Carroll et al., 2011). Patient admission within 30 days is an indicator that patients may not have understood and followed the post-hospital self-care as such compliance to self-care and medication is an important prerequisite for HF patients discharged from hospitals (Silow-Carroll et al., 2011). Some common reasons for HF rehospitalization are delays on the part of patients in the recognition of HF symptoms, lack of dietary compliance, medication, and the deficiency of knowledge and skills for appropriate self-care (Dennison et al, 2011). Patients with serious conditions such as HF face the increased risks of lack of appropriate care, increases rates of hospital readmission, and higher death rates.
A low level of literacy among HF patients is among the important contributors to the rehospitalization of HF patients (Dennison et al, 2011). Health literacy is termed as the ability of patients to learn, understand and use the primary health information related to their health to make suitable decisions related to their health (Dennison et al., 2011). Poor results in Heart Failure (HF) have been associated with poor health literacy and lack of appropriate self-care practices as such improvement of self-care practices is essential for improved outcomes among patients HF (Lee et al., 2009). Research confirms that patients having low health literacy are unable to understand the aspects of managing their disease and are more likely to have serious health outcomes (Dennison et al., 2011). The study by Dennison et al. (2011), authenticates health literacy is essential for the enhancement of health outcomes. Low rates of health literacy and self-care increase the risk of chronic diseases which is why hospitals should pay special attention to enhancing increased health knowledge and self-care to HF patients.
Studies authenticate that enhanced self-care leads to improved health outcomes, which is why teaching self-care practices to HF patients is important (Lee et al., 2009). Self-care in HF refers to the behaviors which help in maintaining the body’s resistance to disease and taking appropriate decisions to manage symptoms associated with HF (Lee et al., 2009). Patients are required to adhere to self-care practices by following the routine self-care practices prescribed by the health care provider.
HF self-care management practice necessitates that patients can quickly recognize any signs of HF as they occur and take instant measures to manage the symptoms through self-directed strategies (Lee et al., 2009). HF patients engaged in self-care practice should be able to understand and quickly improve symptoms of excess fluids of congestion by restricting their sodium or fluid intake. Patients following effective HF self-care practices should be able to gauge the effectiveness of their self-care treatments and monitor themselves attentively. HF patients who are unable to manage self-care practice do not possess the ability to recognize and cater to symptoms or take appropriate to manage them (Lee et al., 2009).
Some self-care practices include regular intake of medication, following dietary restrictions for sodium intake, daily measurement of weight, and careful watchfulness of symptoms (Lee et al., 2009). Regular exercise and avoidance of harmful drugs and adherence to immunizations are important HF self-care practices prescribed to patients. Patients with poor HF self-care practices do not adhere to regular medications and do not comply with the regular intake of sodium and other dietary factors (Lee et al., 2009).
Improvement in the quality of self-care is an area of growing concern for the reduction of hospital readmission. Caregivers and hospitals have realized the importance of medication education and nurse intervention for reducing readmission of HF patients (Silow-Carroll et al., 2011). It has been found that patients discharged from hospitals with poor resources and low nursing staff had higher rates of admission (Joynt & Jha, 2011). Researchers found that patients discharged from public hospitals in the US had a high probability of those discharged from non-profit hospitals (Joynt & Jha, 2011). Studies indicate that the availability of increased nurse staff is directly proportional to better quality care and healthcare outcomes (Joynt & Jha, 2011).
Research confirms that a high level of nursing staff reduced the rates of readmission of HF patients (Joynt & Jha, 2011). Smaller hospitals in rural areas have lesser resources, doctors, nurses, and financial resources, limiting their ability to provide optimal care to HF patients (Joynt & Jha, 2011). As such, expert care in caring for HF patients leads to enhanced health care outcomes. It was found that patients receiving HF care from small hospitals had higher rates of readmission (Joynt & Jha, 2011).
The study of four hospitals emphasized the use of best practices and effective use of the hospital workforce, including nurses and hospitalists to educate patients about self-care techniques and reduce rates of hospital readmission (Silow-Carroll et al., 2011). Silow-Carroll et al., (2011) highlight the significance of involving nurses for better outcomes among HF patients and reduced rates of readmission. Nurse intervention allows to lower patient confusion and reinforces the importance of self-care so that they are better able to follow post-hospitalization care after being discharged.
Nurse intervention can be an effective measure in reducing the risk of readmission of HF patients to hospitals. To reduce the risks of readmission of HF patients, hospitals engage several methods. Among these, ‘teach back’ is an effective approach in hospitals with considerably low rates of readmission of HF patients. Nurses in hospitals provide patients and their families with the necessary instructions of self-care practices to be followed post-discharge (Silow-Carroll et al., 2011).
For instance, Memorial City hospital employs the ‘teach back’ approach (Silow-Carroll et al., 2011). The Hospital nurses thoroughly review the discharge instruction with the patients and their family members. The patients and their families are then asked to ‘teach back” what they have learned from the nurse. This method strengthens the patients’ understanding of the instructions given by the nurse. The approach also enables nurses to identify the areas which may be confusing to patients and their families, leaving no scope for error in comprehension (Silow-Carroll et al., 2011). Similarly, nurses at the McKay-Dee hospital receive training to evaluate patients’ literacy levels so that they can adjust their teaching methods and materials to suit the patients’ understanding. This method allows for nurses to demonstrate instructions in a manner that is easy for patients to understand and remember (Silow-Carroll et al., 2011).
The teach-back is a method employed in hospitals by nurses to educate patients about self-care after discharge (White et al., 2012). The method is highly effective in facilitating education and learning among patients. The method ensures that patients retain the essential information for longer periods as compared to brief teaching methods earlier used (White et al., 2012). The effectiveness of the teach-back method makes it highly suitable to be used for educating HF patients upon discharge. Nurses can use the method to assess the level of learning in HF patients and ensure that the information is deeper and long-lasting. The method helps clear confusion among patients since it allows nurses to assess the level of understanding through the teach-back technique (White et al., 2012). Teach-back ascertains that the information is grounded in patients to be used at home and followed in self-care practices. Research confirms that when patients receive information through the teach-back method which employs longer instruction and assessment time, they are better able to retain the information (White et al., 2012). There is an indication of reduced rates of hospitalization of HF patients who have been mentored by nurses using the teach-back approach.
Intervention
Decrease admission rate of CHF patients by:
- Identifying patients with low levels of health and self-care knowledge
- Provide tailored interventions to patients for improved self-care of patients with HF
- Assessing the patient’s knowledge and learning abilities
- Assessing preferable teaching methods and the preferred language
- Providing appropriate nursing teaching and using an interpreter in case of language problems
- Informing patients of the harmful effects of smoking and alcohol asking them to quit
- Asking patients to monitor and maintain weight daily
- Informing patients to reduce sodium intake
- Telling them to reduce coffee and beverage intake
Educating patients about dietary controls such as the intake of high fat and high cholesterol foods – less oily food intake, avoiding junk food, Intake of Lots of fresh fruits and vegetables.
Using advanced practitioner nurses for the populations at high readmission risk such as the older population
Educating patients about the benefits of daily exercise to maintain health
Evaluation
Readmission of HF patients is an issue of concern to health care professionals. The lack of knowledge among HF patients is an important reason for readmission. Research and studies indicate that when HF patients engage in self-care after discharge, the rates of readmission are reduced. Nurses play an important role in assessing the healthcare literacy levels of patients and educating them about the essential self-care techniques. Teach-back is an effective approach in educating patients since it helps patients better understand and retain the self-care measures to be used at home.
References
Dennison CR, McEntee ML, Samuel L, Johnson BJ, Rotman S, et al. (2011) Adequate health literacy is associated with higher heart failure knowledge and self-care confidence in hospitalized patients. Journal of Cardiovascular Nursing. 26: 359–367.
Joynt, K. E. & Jha, A.K. (2011). Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circulation: Cardiovascular Quality and Outcomes. 2011; 4: 53-59. Web.
Lee, C.S., Tkacs, N.C., & Riegel, B. (2009). The influence of heart failure self-care on health outcomes: Hypothetical cardioprotective mechanisms. Journal of Cardiovascular Nursing, 24(3), 179-189.
Silow-Carroll, S., Edwards, J. N., and Lashbrook, A. (2011). Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals. New York: The Commonwealth Fund.
White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. (2012). Is “Teach-Back” Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients? Journal of Cardiovascular Nursing. Vol. 28, No. 2, pp 137-146.