Heart Failure Discharge Plan
Capella University
Leadership and Management
Assignment 3
Heart Failure Discharge Plan
The leadership team has asked that a nurse-run outpatient heart failure clinic be initiated in order to reduce the readmission rates of heart failure patients being discharged from the hospital. This clinic is being put in place to ensure that patients are receiving adequate discharge teaching before going home. The clinic will serve as a central location that the patients will visit for education and resources once leaving their areas within the facility and prior to being discharged. The clinics goals are to have ninety percent of patient enrollment, one hundred percent patient compliance with education, and a readmission rate decrease by five percent over the next year. Meeting the above stated goals, or continuously moving in a positive direction of the goals, will predict the success of the program.
Care Plan
The discharge education plan will discuss how the patient can monitor their daily progress and activities and available resources. The care plan will also cover education for self-care, prevention, and lifestyle changes needed going forward. It will also discuss any cultural or social accommodations, current heart failure guidelines and standards, follow up recommendations, and procedures or tools to measure effectiveness of the clinics program. All information will be covered in person in detail with the patients.
The clinic should have several different ways of delivering this information to the patient along with face to face. The staff should ask the patient the best way they learn and use that method in conjunction with the face to face education. These methods can be charts and pictures, demonstrations, hands on learning tools, audio versions to follow along in a book or handout, or even online learning with interactive options. There must also be a language line or video interpreter available as well. Once the patient has finished each section of the educational area, they will be required to answer questions or do a teach back method to check for understanding.
The heart failure clinic will be nurse-run, but also consist of many different team members who will be involved. While there are many people within this interprofessional team, continuity of care, education, and communication is of the upmost importance for the patient’s outcomes and management. The transition for these patients from admission to the hospital to outpatient can be overwhelming and a vulnerable time. Therefore, it requires a large number of people working together to meet the patients needs. This team can consist of many disciplines including, but not limited to: heart failure clinic nurse, primary care physician, cardiologist, case manager, family members, palliative care team, spiritual/cultural support, pharmacist, dietician and social worker.
Self-care, prevention, and lifestyle changes
Medications. Information regarding the patient’s medications must be discussed in detail to insure they understand when and how to take their medications. Depending on which issues the patient had that led to heart will failure will determine the class of medications the patient is on for their regimen. For example, “In all patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and cardiovascular events” (JACC, 2013). The clinic must also assess the ability for the patient to obtain their medications they need, and other meds to discontinue as well. Provide the patient with a list of medications, how to take them, when to take them, and a pill organizer should be provided if the patient doesn’t have one already.
Daily weights. Instruct the patient on how to correctly obtain their weight every day to keep track of. Patient’s must weight themselves every morning after emptying their bladder, and prior to eating breakfast. They need to wear lightweight clothes that are similar in weight as well. The patient needs to record their weight every day to report it to the care team. Inform the patient they must call their doctor if they gain more than the 3 pounds in a day or 5 pounds in a week, per the AHA guidelines. Confirm that the patient has a scale at home, if not, provide one.
Diet. Patients with heart failure must understand the importance of a low-sodium and low-fat diet, as this can lead to fluid retention which can exacerbate symptoms. The clinic should provide a list of recommended and restricted foods, along with a food diary for tracking. The patient must also be informed to not consume alcohol as well. The clinic staff needs to assess the patient’s ability to obtain healthier food options, while being conscience of any cultural or socioeconomic factors. The clinic must provide resources to the patient and family if they need help with access to healthy food options.
Physical activity. Clinic staff must discuss in detail the approved exercise and daily activity level prescribed by the physician specifically for that patient. The patient must understand to take rest periods and breaks whenever necessary. The patient should avoid any heavy lifting, pushing, or pulling of heavy objects, especially if any implantable device therapy is in place. If any cardiac rehab was ordered, this must be discussed in detail and set up prior to leaving the clinic. Patients and physicians should discuss resuming sexual activity also.
Follow-up appointments and referrals. “The institution of a structured system of patient and family education that involves a multidisciplinary team and emphasizes medication adherence, sodium and fluid restrictions, and recognition of signs and symptoms that indicate progression of disease may be as important as ensuring that patients are prescribed appropriate medical therapy” (Paul, 2008). The clinic must make sure that the patient has a follow-up appointment schedule with their physician within seven days of discharge, or within three days if they are high risk. If the patient has not already made this appointment themselves, the clinic must do it to insure continuation of care and management. The clinic should provide the patient with all contact info for the appointment, including date and time. The clinic should assess for the patient’s ability to make the appointment, including transportation, funds, or disease process. If there are any barriers found to be present, the clinic should set up resources to help the patient attend their appointment in order to not delay care. The clinic may follow up within three days to make sure everything is still in place and ready to go.
Part of the clinic’s most important factors will be to make sure the patient has all necessary resources they need once they get home before they leave. In addition to the clinic’s handouts/booklet they will receive, they should also provide a list of resources the patient can utilize online or locally if they need. Some examples of online resources are the American Heart Association and Heartfailurematters.org, and Mended Hearts. Locally they can use their care team and physicians, the heart failure clinic, local hospitals and United Way. Should the patient end up needing palliative care services, the clinic should assist with the startup process with it.
Comorbidities in heart failure. It is important to address any comorbidities that the patient has that can develop or contribute to the patient’s diagnosis in heart failure. Some examples of important considerations in relation to heart failure are: atrial fibrillation, anemia, hypertension, hyperlipidemia, diabetes, chronic kidney disease, COPD, and Alzheimer’s/dementia. Each must be discussed in detail with how they may affect the patient and how to manage the disease in conjunction with heart failure. The care team must also address any secondary prevention interventions such as smoking cessation and influenza and pneumococcal vaccines.
Symptoms and when to call for help. After discussing all the previous educational needs, the staff should describe any symptoms the patient may experience and when to call the MD or 911. Some signs and symptoms needing to be addressed in detail are: weight gain of 3 pounds in 1 day or 5 pounds in a week, shortness of breath or increased effort to breathe at rest, dizziness, increased swelling or edema (feet, ankles, legs, or stomach), increased fatigue or feeling tired, new or worsening chest pain, and confusion. Some of these signs may be due to an emergent situation or perhaps a change in medication dosage.
Tools for monitoring. Everyone who enrolls in the heart failure clinic should be given all the tools and educational resources available to take home with them upon discharge. Any extra resources available for hands on learning and visuals will only help the patient and family members succeed at managing the disease. Some of these tools were previously mentioned, but some were not, these will be in the handout packet each person receives:
- Daily weight record
- Restricted and approved food lists with food diary
- Medication list and pill organizer
- Color coded HF zones chart of symptoms and when to call MD
- Calendar to keep up with appts
- DVD and internet links for recipes, education, self-care
- AHA HF Path app to download to smart phone: “a self-management tool that empowers heart failure patients to better manage and live with their condition” (AHA, n.d.).
- heart.org > health topics > heart failure > tools and resources > HF path self-management tool
Professional and legal standards
Heart failure guidelines and standards. Throughout the care plan we addressed some of the standards the patients must follow upon discharge due to their diagnosis of heart failure. The most recent heart failure guidelines come from the American College of Cardiology Foundation and the American Heart Association task force on practice guidelines. According to the Journal of the American College of Cardiology (2013):
Experts in the subject under consideration are selected to examine subject-specific data and write guidelines with representatives from other medical organizations and specialty groups. They are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered.
The guidelines set as the standard for all healthcare settings across the nation. The clinic must adhere to these guidelines when developing the discharge education plan as to not assume any legal actions for unethical care and patients’ rights. The clinic must fully address any quality of life issues with the physicians as well so that the patient knows the projected outcomes from the beginning. “The increasing ability of medicine to keep patients with advanced heart failure alive for years raises the debate about the tradeoff between quality of life and quantity of years of life” (Fields & Kirkpatrick, 2012). The heart failure clinic should consult with a medical ethics committee throughout the entire process of starting the clinic and admitting patients into the program.
Evaluation and conclusion. As previously stated, meeting the goals of the clinic will evaluate the success of the heart failure clinic discharge program. Patients will be enrolled in the program and complete a pre-test of knowledge at that time, known as the Dutch Heart Failure Knowledge Scale (DHFKS). “This 15-item multiple choice questionnaire has been found to be a valid and reliable instrument to measure patients’ knowledge of symptoms related to CHF, medication compliance, diet, fluid allowance, and physical activity” (Boyde et al, 2013). The same questionnaire will be given 6 months post their discharge date. Afterwards the staff will use the statistics of the pre and post-test answers to assess for success as well. Another way to possibly evaluate the success of the program is using pre and post lab work to compare certain levels.
The success of the program relies heavily on everyone in the care teams abilities to work together to improve the quality of life in these patients and reduce the readmission rates to the hospital in regards to heart failure.
References
American Heart Association. (n.d.). HF path self-management tool. Retrieved from: https://www.heart.org/en/health-topics/heart-failure/heart-failure-tools-resources/hf-path-heart-failure-self-management-tool
Yancy, C., Jessup, M., Bozkurt, B., Butler, J., Casey, D., Drazner, M., ……Wilcoff, B. (2013). 2013 ACCF/AHA Guideline for the management of heart failure. Journal of the American College of Cardiology, 62 (16), pp. 147-239. DOI: 10.1016/j.jacc.2013.05.019
Paul, S. (2008). Hospital discharge education for patients with heart failure: what really works and what is the evidence? Critical Care Nurse, 28 (2), pp. 66-82.
Fields, A. V., Kirkpatrick, J. N. (2012). ETHICS OF THE HEART: Ethical and policy challenges in the treatment of advanced heart failure. Perspectives in Biology and Medicine, 55(1), 71-80. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F935849321%3Faccountid%3D27965
Boyde, M., Song, S., Peters, R., Turner, C., Thompson, D. R., & Stewart, S. (2013). Pilot testing of a self-care education intervention for patients with heart failure. European Journal of Cardiovascular Nursing, 12(1), 39–46.
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