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A multivariate analysis of readmission rate among heart failure patients identified severity of illness and functional status as well as the presence of comorbidities such as depression and lack of social support as predictive of readmission of heart failure within 3 months.5 Kassovsky et al. retrospectively evaluated unplanned readmissions for heart failure within 31 days of the index heart failure admission. In addition to age and history of revascularization, they found lack of readiness for discharge in the index hospitalization as a predictor of readmission.6 Readiness for discharge was defined by a stable cardiac medication regimen for at least 24 hours; no evidence of deterioration of laboratory results, vital signs, or physical examination findings; and documented dietary education and postdischarge plans.
Integrating inpatient and outpatient care begins while the patient is hospitalized, with an assessment both at the beginning of and throughout the hospitalization of an individual patient’s social and psychological issues that may affect compliance with a complex regimen. Identification of potential barriers to a patient’s understanding of their illness, such as cognitive deficits or their ability to read and understand the language that is being used to communicate with them, is of basic importance. Assessment of financial considerations that may impede their compliance with medical and general care regimens remains important, as is the identification of community and governmental services that can be deployed to help overcome these and other barriers. An understanding of a patient’s ethnic traditions can also assist in designing a long-term care plan that takes both their beliefs about health care and their medical program into consideration. Any barriers to adherence to self-care should be addressed prior to discharge.
The performance of this assessment while improving the patient’s medical condition can be challenging, especially when issues of length of stay are also stressed. The use of multidisciplinary teams, in both inpatient and outpatient settings, can add to the effectiveness of an outpatient heart failure regimen.7 A randomized controlled trial of multidisciplinary team care of heart failure patients transitioning from the inpatient to outpatient setting showed a significant decrease in readmission rates.8 Such a team can also have a beneficial effect on an individual health-care provider’s effectiveness and job satisfaction, although this has not been formally studied.
Medical Treatment
Guidelines have clearly outlined recommended medications for heart failure due to left ventricular systolic dysfunction.2,9 The evidence for the benefits of treatment with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), b-blockers, hydralazine and nitrates, diuretics, anticoagulants, and heart failure device therapies are outlined, as are the appropriate patient subgroups in which they should be used. At this time, the guidelines for diastolic dysfunction are less extensive, emphasizing the treatment of the underlying cause such as hypertension, and the use of diuretics to minimize congestive symptoms. Importantly, the initiation of appropriate medical therapies to heart failure patients during hospitalization has been shown to improve the frequency of their use after the patient is discharged. The Initiation Management Predischarge process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) trial demonstrated a higher rate of outpatient b-blocker utilization if therapy was started during inpatient hospitalization rather than following discharge.10
Insurance formulary restrictions on medications must be kept in mind when selecting among possible therapeutic options within a class of agents. Although short-acting medications are often used on inpatients for careful titration, they have the disadvantage of requiring multiple doses during the day. Adherence to medication treatment plans falls off quickly when patients are required to take medications more than twice daily. Adjusting medications to longer-acting preparations prior to discharge will help to promote adherence and could prevent readmission. Where these longer-acting preparations will result in higher costs to the patient, a discussion with the patient as to their preference can avoid discontinuation of an important therapy when the patient is faced with a high payment at their pharmacy after discharge. Some patients are willing to pay more in order to have the convenience of once- or twice-daily dosing. Enlisting the patient in decisions such as this helps to promote their ownership of the plan. If patients have no medication coverage and cannot afford medication, consultation with case managers, social workers, or financial counselors should be sought well before discharge.
Education
Assessment of patient’s knowledge or predetermined misconceptions about their illness is an important start to the education process. Information about heart failure and its treatment should be geared toward the person’s cognitive ability, ability to learn, and level of schooling. Understanding the pathophysiology of heart failure in appropriate lay terms can lay the basis for adherence to medical regimens. Health-care providers should teach patients about their heart failure in person, either alone or preferably with their families. A hospitalization creates an opportunity for education about heart failure, if only because of the focus that can be brought to bear by multiple professional caregivers and also because of the patients’ increased motivation to take better care of themselves so as to avoid readmission. However, since patients’ retention of much of what they are taught during an inpatient stay can be limited, having a family member present may help to fill in gaps once the patient has been discharged. In addition, outpatient reinforcement of key educational messages may help patients to consolidate this important fund of knowledge. Written information about pathophysiology, medications, dietary restrictions, daily weights, and follow-up will also reinforce teaching, but it should be accompanied by direct contact with a health-care professional that can individualize a patient’s learning and address questions and concerns.
For patients who cannot read, possible alternatives should be provided: videotaped information, a schedule of outpatient classes, consultation with an outpatient heart failure health advocate, and a telemanagement program or home health-care provider. These patients will benefit from earlier and more frequent follow-up after discharge to reinforce their learning and prevent adverse outcomes.
Heart failure patients are often older, and may be sensory-impaired or cognitively impaired. Hearing impairment can interfere with the effectiveness of teaching. Some patients are embarrassed and will nod in agreement rather than admit to being unable to hear teaching or discussions. If the patient has a hearing aid, make sure it is functional and that the patient is wearing it. If the patient is cognitively impaired and will be going home with family, several sessions of teaching time with the family should be arranged. In this way, if family members have digested the information and have questions or concerns, there is opportunity to address them.
Other important methods of learning occur through the regular inpatient routine. Recording daily weights during a hospitalization is extremely important as role modeling for patients and provides an opportunity to discuss how a patient should manage these results at home. Discussing dietary choices on menus and delivered food trays is a practical method of reinforcing sodium and fluid restrictions. Evaluation of exercise tolerance in the hospital can be an occasion to discuss exercise schedules at home as well as symptoms and how to manage them. Interpreters should be available when necessary for assessment and educational encounters, as well as for discharge teaching.
Sodium Restriction
Education on sodium restriction should include reasons why it is necessary, including the adverse effects of lack of compliance on quality of life. A review of foods high in sodium, typical 24-hour dietary recall, how to read nutritional labels, and how to eat out in various restaurants will provide a basis on which the patient can function. Having the patient recall their dietary choices for the 24–48 hours prior to admission can be particularly instructive and offer an opportunity to explore alternatives that are palatable.
Different ethnic preferences need to be addressed in dietary considerations. If certain (high sodium) dishes are important to a person’s identity, the dietitian should be consulted for assistance in finding a way to adapt that food in a healthy way if possible, and to emphasize the role of that food in the total daily dietary sodium allotment as a means of permitting its use in a limited quantity.
Meals on Wheels or other food programs for elders and indigent patients may not be as low in sodium as desirable. The monitoring of daily weights and close follow-up with health-care providers should be strongly considered in these cases.
When patients seem overwhelmed by the amount of dietary education, or are upset with a perceived large dietary change, it may take some time and compromise to reach healthier dietary habits. Ultimately good dietary habits provide positive reinforcement. In the interim, however, it may be useful to invoke the “80/20” rule used in business management: 20% of what you do causes 80% of the problem. A good dietary history may provide information about significant culprits that the patient is willing to eliminate, moving the patient closer to an ideal regimen.
Daily Weights
Assessment and treatment of a heart failure patient’s volume status is often guided by the measurement of daily weights. Discussion of daily weights should assure that the patient has a working scale at home; if not, the patient should be instructed to have family members or friends purchase one prior to the patient’s discharge. Hospital staff should determine that the patient can get on the scale and can read the results. For those who cannot afford them on their own, case managers may be able to explore other mechanisms for obtaining scales. Some heart failure programs have included the provision of scales to patients who cannot afford them as a routine part of the discharge planning process. Patients should be taught to weigh themselves at the same time each day and to keep a log of their weights. Making sure that daily weights are done in the hospital is an extremely important method of teaching patients by role modeling and by discussing the interpretation. Finally, patients should be taught the use of a sliding scale diuretic regimen or be given parameters for when to call their provider.
Fluid Restriction
For some patients, fluid restriction is necessary, and often difficult. Patients need to be taught in terms that are available to them in the real world, such as 2-liter bottles and ounces, not in milliliters (rare) and ccs/cubic centimeters (almost never). A 24-hour recall can be a starting place. The total daily allotment of fluid can be apportioned among meals and an in-between meal allocation so that patients can avoid consuming the entire allowed amount prior to the end of the day. Providing coaching with meals that are delivered to inpatients may help to clarify that soup and gelatin are considered fluids. In the hospital and at home, patients can visually keep track of their fluid intake by filling a 21 soda bottle or milk jug with an equivalent amount of fluid. Hard candies or frozen grapes can be offered to help to alleviate thirst.
Symptom Recognition
During the hospitalization, while more intense observation is available, providers should try to determine the particular constellation of symptoms for that patient. For example, an older thin female with diastolic dysfunction with some right-sided heart failure may have a 1-lb weight gain, mild bloating, and mild ankle edema that are relieved with mild diuretic adjustment. Other patients may need to recognize that the development of dyspnea with personal grooming or while washing dishes is indicative of a need to augment their diuretic regimen. Teaching symptom recognition and stressing specific signs may help the patient retain the information after discharge. Helping patients recognize their symptoms may lead to earlier treatment and prevention of hospitalization.
Exercise
Exercise can be an important component of both inpatient and outpatient treatment plans for patients. Long periods of immobilization can be deleterious to patients; symptoms associated with deconditioning can be confused with symptoms of congestion. Increases in activity can be encouraged once symptoms are better controlled; some concrete methods of determining a patient’s readiness to increase activity and initiate an exercise program include the ability to speak without
dyspnea, a resting heart rate less than 120 beats/min, or the occurrence of no more than moderate fatigue with activities of daily living.11 While increasing activity, the rating of perceived exertion (RPE) scale can be used to evaluate level of exertion. Often patients can benefit from working with a physical therapist after a moderate period of inactivity within the hospital, and this can occur on both an inpatient and an outpatient basis. Enrollment in a cardiac rehabilitation program can help to facilitate the development of an outpatient exercise program, but one must ensure that the program’s staff is oriented to the needs of a heart failure patient, which may differ from those of patients with ischemic heart disease.
Social Support
The level of social support available to patients may be a factor in their recovery and ability to stay out of the hospital. As previously noted, the amount of information to be absorbed during hospitalization can be overwhelming for one person; the presence of family or companions at key points during the education process can be important in providing a source for missed information. Enlisting family or community resources prior to discharge can also assist in maintaining a heart failure patient’s well-being afterward, as these patients often suffer from fatigue, an energy limitation that limit their ability to care for themselves. Simple activities such as shopping, food preparation, filling pillboxes, or refilling medications may not be manageable for some patients. Depression, which is a predictor of readmission for heart failure, is exacerbated by a lack of social support. Supplemental supports to be evaluated prior to discharge include the Visiting Nurse Association (VNA), and home health aides as well as governmental or nongovernmental elder services programs. In a multidisciplinary approach, both social workers and case managers provide invaluable assistance in finding support and guidance for patients. Even informal social support offered to the patient by the inpatient caregivers has been shown to be effective in decreasing the 3-month readmission rate.5
Comorbid Illnesses
Diabetes and depression are both associated with worsening heart failure. Hospitalization is an opportunity to address and improve care for both of these conditions. Renal failure can greatly complicate the treatment and prognosis of a patient with heart failure, making diuresis more difficult and exacerbating prerenal azotemia that can occur with a diminished cardiac output.12,13 Consultation with a nephrologist may assist in the treatment of reversible causes of renal dysfunction as well as identify the occasional patient for whom dialysis may be necessary for control of their volume status.
Other Factors
There are certain drugs that can cause worsening heart failure symptoms. These include non-steroidal anti-inflammatory drugs (NSAIDS) and thiazolidinediones (rosiglitazone and pioglitazone). Patients are advised against taking NSAIDS as they cause renal sodium retention. A 2002 review of thiazolidinediones by the U.S. Food and Drug Administration (FDA) advised against this class of drugs in Class III and IV heart failure and cautioned careful observation of other patients with heart failure. Cephalosporin therapy can decrease the effectiveness of loop diuretics, and a patient should be cautioned to monitor their weight closely during the period for which they are prescribed. Smoking cessation counseling should be provided or reinforced.
Heart Failure Severity
The amount of outpatient support a patient will require is often predicted by assessment of heart failure severity. The New York Heart Association (NYHA) classifications essentially are measures of functional status and have traditionally reflected HF severity. Patients with NYHA Class I or II functional capacity may benefit from outpatient education and uptitration of medication to evidence-based target levels. Patients with Class III or IV heart failure usually require closer and more frequent attention.14 Patients who are being evaluated for heart transplant are likely to be connected to a heart failure specialist team for management. Some patients are on chronic infusion therapy; their discharge preparation is more involved. Patients with ventricular assist devices for destination therapy should be followed in a formal ventricular assist device (VAD) program.
Those with end-stage heart failure benefit from thoughtful discussions about end-of-life issues, comfort measures, and preferences for treatment. Studies have shown that a person’s priorities and preferences for end-of-life treatment may vary or evolve over time.15 Many hospitals offer consultation from palliative care services that can help provide patients and clinicians with decision-making options. Hospice services, either inpatient or at home, are an option for further care. While eligibility for hospice usually includes likelihood of death within a 6-month time frame, the results from the Supplemental Benefit of ARB in Hypertensive Patients with Stable Heart Failure Using Olmesartan (SUPPORT) trial demonstrated the difficulty in predicting timing of death, with as many as 77% of patients meeting hospice admission criteria alive 6 months later.16,17 Thus providers must be flexible as they offer a prognosis. Hospice also usually precludes use of advanced medical therapy, such as intravenous inotropes. However, distinctions in the availability of advanced therapies as opposed to palliative care in the hospice setting are evolving, allowing patients to receive the medical comfort and social support traditionally available through hospice care, while at the same time letting them receive sophisticated medical treatments (Abelson, R “A chance to pick hospice, and still hope to live.” The New York Times, published 2/10/07).
INTEGRATION TO OUTPATIENT CARE
Too often, there is a gap between inpatient and outpatient care. Referral to appropriate follow-up care and thoughtful communication from inpatient to outpatient clinicians is critical.18 A recent meta-analysis of over 3000 patients age 65 or older with heart failure found that comprehensive discharge planning combined with postdischarge support leads to a reduction in readmission risk of 25%, improved quality of life, and a reduction in the patients’ medical care expenses.19 Possible follow-up for patients includes primary care practice, general or heart failure cardiologist, general or specialized VNA services, specialized heart failure clinics, disease management programs, and cardiac rehabilitation. In this section, the potential issues that need to be addressed to facilitate coordination of a patient’s inpatient care with an appropriate outpatient medical support program will be discussed.
Communication
Communication is vital in a variety of areas. Written communication with the patient consisting of clear discharge instructions for medications and their timing, diet, and follow-up plans reinforce verbal teaching. Discharge summaries are often the primary source of communication with primary care or referring physicians. The quality and timeliness of discharge summaries are important for outpatient care. Several factors have been noted to be important in transfer of information: discharge medications, recent laboratory values, ejection fraction, and timeliness of discharge summary preparation.20 Continuation and uptitration of evidence-based medications can also be emphasized through discharge summaries. Often, there are multiple providers, increasing the complexity of effective communication. Timely dissemination of data to all providers is important.
Harrison et al. have identified “intersector linkages” in the transition from hospital to home for heart failure patients.21 These linkages emphasize consistency in educational efforts and communication between the hospital nursing staff and home care nurses during the vulnerable period immediately after discharge, and are compared with a traditional model for the transition from inpatient to outpatient care in Table 20-1. Improvement in quality of life and reduced emergency room visits resulted.
As noted, the immediate postdischarge period is critical. Home care nurses and/or follow-up phone calls to patients can answer questions, ensure that prescriptions have been filled, and essentially put out any preventable fires. Although Medicare currently requires patients to be home-bound for continuous visiting nurse visits, usually an initial evaluation visit can be arranged. In some areas, VNAs have clinicians who have specialized heart failure expertise. Discharge planners or case managers in hospitals should be able to identify availability for a particular patient.
Disease Management Programs
As noted in Chap. 18, disease management programs have been shown to be very helpful for managing patients with chronic disease. This is especially true for heart failure patients, where disease management results in reduced emergency room visits, readmissions, and mortality and improved quality of life.22,23 These programs come in many shapes and sizes; studies are often done on small numbers and the variability among the interventions makes them difficult to compare or categorize or meta-analyze. Programs are usually based on telephone contact with nurses, pharmacists, or specially trained personnel, and may include home nurse visits or clinic appointments after discharge. Importantly, such programs often comprise the critical link between the inpatient and outpatient environments, thus promoting better continuity of care.
Telephone contact programs vary in their content and approach:
* Coaching: primarily education, problem solving, and encouragement to maintain advised treatment regimen.
* Clinical evaluation ± treatment: with assessment of symptoms, weights, and medications and education; nurse caller either reports back to physician with results of encounter or first adjusts medications (usually diuretics) according to standing orders and then reports to referring provider.
Home visits have been done by specialized nurses or nurse practitioners who have been able to perform clinical assessments and possibly make changes in the field. Additionally, they can assess home situations and dietary and medication adherence in ways probably more reliable than self-reporting. If available, this approach may be preferable for frail at-home elders, patients with frequent readmissions, and those whose compliance is questioned. Office visits to specialized heart failure clinics can provide opportunity to educate, assess, adjust treatment regimens, and provide access to other members of the multidisciplinary team: nutritionists, physical therapists, social workers.
Advantages of formalized programs include skilled clinicians; an approach to evidence-based medicine with protocols directing the uptitration of medications to optimal dosages; access to nutrition specialists with knowledge of diverse ethnic backgrounds; and collaborative associations with access to physician specialists. Communication among all clinicians and with patients is key to caring for these patients. Programs of greater intensity in terms of visit frequency and assessment are preferable for persons with Class III or IV symptoms. Although they have been shown to reduce hospitalizations and emergency room visits, heart failure disease management programs, or any intensive follow-up, are not without cost.23 Insurance coverage needs to be considered. Some programs are sponsored by insurance agencies and CMS may assist in payment for certain programs.24
Inotropic Support
Patients who are dependent upon inotropic infusions require close follow-up. Specialized infusion companies, often in collaboration with visiting nurses, or outpatient heart failure clinics provide assessment and care of infusion issues. These patients will also benefit from more intensive outpatient management.
Ventricular Assist Devices
Patients who have had mechanical circulatory devices placed have a very different set of requirements.25 Transition to home requires medical stability and intensive therapy to resolve possible major reconditioning issues. The hospital-based program provides education for community resource personnel, such as EMTs, police and fire department personnel, and local emergency room staff.
SUMMARY
Caring for heart failure patients and implementing the care described is too large a task for one person. Current practice demands make it difficult to provide the amount of time and effort necessary to provide adequate assessment, education, and treatment. Multidisciplinary teams are extremely important in providing quality care to heart failure patients. Assuring a smooth intersection between the inpatient and outpatient arenas should help to provide a stable course for patients, without backsliding on important gains made during hospitalization and preventing rehospitalization. It should also increase satisfaction among patients and all providers.
REFERENCES
1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics—2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85–e151.
2. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA guidelines for evaluation and management of chronic heart failure in the adult2005. Circulation. 2005;112:e154–e235.
3. Armola RR, Topp R. Variables that discriminate length of stay and readmission within 30 days among heart failure patients. Lippincotts Case Manag. 2001;6:246–255.
4. Dicker RC. Introducing the Medicare quality of care surveillance system. Quality Resume, No. 1. Baltimore: Health Care Financing Administration, 1997.
5. Schwarz KA, Elman CS. Identification of factors predictive of hospital readmissions for patients with heart failure. Heart Lung. 2003;32:88–99.
6. Kassovsky MP, Sarasin FP, Perneger TV, et al. Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient characteristics? Am J Med. 2000;109:386–390.
7. Grady KL, Dracup K, Kennedy G, et al. Team management of patients with heart failure: A statement for healthcare professionals from the cardiovascular nursing council of the American Heart Association. Circulation. 2000; 102:2443–2456. |
