Congestive Heart Failure: Reducing the Hospital Readmissions


Congestive heart failure (CHF) is a considerable bother for healthcare both in the US and internationally. CHF treatment is associated with an increased number of hospital readmissions, especially for older adults, which leads to additional health costs. However, according to Hasanpour-Dehkordi, Khaledi-Far, Khaledi-Far, and Salehi-Tali (2016), multidisciplinary disease management programs including nurse education interventions can significantly lower the chance of patients with CHF being admitted to cardiac centers for the second time. The present project aims at designing a process that can become a cost-efficient method to reduce hospital readmissions and associated spending.

The Spirit of Inquiry Ignited

CHF is a manageable and preventable condition in all patient groups including older adults. However, according to Ziaeian and Fonarow (2016), approximately 37.7 million people suffer from CHF globally. The authors also note that the total spending on patients with CHF was estimated at $20.1 billion and is expected to increase by 2030 significantly (Ziaeian & Fonarow, 2016). They also state that over 5.7 million citizens of the US were diagnosed with CHF and each year approximately 870,000 patients develop the disease (Ziaeian & Fonarow, 2016). The overall data provides an understanding of the fact that the number of CHF cases continues to increase every year.

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The specific manifestation of CHF may vary, depending on a particular patient. Individuals with CHF may not experience any of the symptoms for years because the heart can compensate for its inefficiency (Cox, 2017). However, standard features include the inability to exercise, weight loss, abnormal perfusion, hypertension, and overload of the refractory volume (Ziaeian & Fonarow, 2016). The majority of complications arise from the heart’s ability to compensate for insufficient performance (Cox, 2017).

For instance, it can enlarge itself to have more power for pumping blood (Cox, 2017). Moreover, the heart can develop more muscle tissue or increase the rate of its beating to work through a sufficient amount of blood (Cox, 2017). While these approaches help mitigate acute complications in the short term, the long-term consequences are weakening of the muscles and fluid buildup.

In my nursing practice, it has been noted that people having CHF are usually older adults with a history of cardiovascular conditions. These patients are frequently readmitted to the hospital for monitoring, which involves cost-efficiency issues. I could often see how they came to make sure that their condition was normal without an evident need for check-up procedures. Some doctors started suggesting that it was not necessary for certain patients with class I and class II CHF to be accepted for monitoring.

Instead, patient education about CHF risks and ways of preventing the illness was provided. The patients were asked to report to the hospital if they experienced any deterioration in their condition and no further appointment was scheduled. The process seemed like a cost-effective way to approach the issue; however, there arose a concern if evidence-practice (EBP) could confirm that the approach was adequate.

The PICOT Question Formulated

Among older adults with CHF in LRH cardiac units (P), is the implementation of a plan to improve health literacy (I), compared with frequent re-admission to the hospital (C), more cost-effective for the healthcare system (O) in 6 months (T)?

Search Strategy Conducted

Before starting the search for evidence in the area of the chosen PICOT question, it was beneficial to evaluate digital libraries for relevance. During the assessment five databases, including CINAHL, PubMed, the Cochrane Library, the National Guidelines Clearinghouse, and the TRIP Database were accessed. A brief search was conducted in all the databases, and the results were evaluated for relevancy of the results. Even though most of the accessed libraries provided access to helpful articles, it was decided to use PubMed articles, as the search output of the library was the most reliable. During the search, many word combination and single keyword searches concerning low health literacy in older adults were conducted.

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Critical Appraisal of the Evidence Performed

The evidence acquired from the PubMed search results was analyzed, evaluated, and synthesized. Huan et al. (2015) conducted research concerning the health literacy level of veterans and its influence on hospital readmission rates. In the course of their retrospective study of 92,749 veterans, Haun et al. (2015) concluded that lower health literacy is a significant factor that provokes increase access to healthcare and additional cost issues. Cajita, Cajita, and Han (2016) conducted a systematic literature review to find out how many Americans living with CHF have limited knowledge about the nature of the disease.

It appeared that approximately 39% of people diagnosed with heart failure have low literacy and health care professionals have to “adopt strategies that can potentially mitigate the impact of low health literacy when communicating with HF patients” (Cajita et al., 2016, p. 128). Hasanpour-Dehkordi et al. (2016) offer a nursing intervention that promotes extensive family education concerning CHF to reduce the readmission rates. These three studies were found relevant to the present research.

Further research confirmed that there is a significant number of interventions that can be utilized by nurses to improve the cost-efficiency of CHF treatment. For instance, Howie-Esquivel et al. (2015) suggest a TEACH-HF intervention that is based on Teaching, Education, Appointments, Consultations, and Home phone calls. This intervention was evaluated to save 641 bed days with potential revenue of $640,000 (Howie-Esquivel et al., 2015).

Additionally, Ziaeian and Fonarow (2016), review several therapies that support the reduction of readmission rates and can be used by both nurses and physicians. The authors state that the majority of the strategies are underutilized, which can be associated with additional costs (Ziaeian and Fonarow, 2016). As a synthesis of all the reviewed articles, it was concluded that interventions aimed at improving health literacy reduce readmission rates and lead to a significant decrease in healthcare costs.

For the current project, it was decided to use a modified TEACH-HF intervention that was entitled TECH (Teaching, Education, Consultations, and Home phone calls) Support. The nursing theory developed by Howie-Esquivel et al. (2015) was modified to suit the older population, as they often find it challenging to show up for additional appointments. It was established to create a short teaching session conducted by a nurse shortly after the admission that included information about the signs of health deterioration and risk factors.

The course promoted lifestyle alterations and encouraged the patients to call the appointed nurse if further consultations were necessary. Additionally, during six months, the nurse called CHF patients once a month to check if there were any changes in their health. The purpose of the presented EBP change project was to implement and evaluate the outcomes of the TECH Support intervention.

Evidence Integrated

Before the start of the project, the nursing theory had to be translated to create a 20-minute training session shortly after the admission to a cardiac unit. As proposed by Howie-Esquivel et al. (2015), the educational part was focused on three areas, including “self-monitoring skills, diet modification, and warning signs for action” (p. 202). The results of the session followed by nurse consultations and phone calls for adults aged 65-80 in a small LRH cardiac unit in the United States were evaluated to assess the feasibility of the TECH Support intervention.

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When older adults are accepted to cardiac units, their treatment mostly consists of medications, lifestyle alterations, and monitoring. However, Class I and Class II CHF can exclude heart medication in some cases and self-monitoring can be promoted. Depending on a patient’s preferences and careful professional assessment, a qualified nurse and the patient can develop a strategy to address the condition from a long perspective.

As for the implementation of the project, 18 adults aged 65-80 enrolled in the project. All the patients agreed to receive TECH Support after it was explained, reviewed, and offered as an option, and signed informed consent. There were no evaluation forms needed, as the purpose of the project was to measure and compare readmission rates. However, all the patients were interviewed by phone at the end of the intervention to gather feedback and personal opinions about the project.

Outcome Evaluated

For outcome evaluation, it was decided to compare 180 days readmission rate of older adults with CHF treated at the unit with the participants of TECH Support. According to Hughes and Witham (2018), on average 21.1% of patients returned to hospitals with the same condition during 180 days. In the LRH cardiac center, where the project was implemented, the readmission rate of CHF patients aged 65 and higher was 28%, which makes it significantly above average.

All the 18 participants of TECH Support went through the teaching session, and seven of them frequently called the assigned nurse for consultations. The nurse called the patients on the phone for monthly check-ups and asked the patients for feedback during the last phone call. The outcomes were evaluated through a simple statistical test, where the number of readmitted patients was divided by the total number of participants and multiplied by 100%.

In the 180 days, three of the patients were admitted to the facility with CHF, which accounts for 16.7%. Therefore, it was concluded that TECH support has the potential to become a cost-efficient method for reducing readmission rates among the senior population diagnosed with CHF. Additionally, the feedback gathered from the participants demonstrated an increased level of patient satisfaction with the intervention.

Project Dissemination

The results of the project were shared with the head of the LRH cardiac center, where it was implemented. Even though he was pleased with the results, he admitted that additional evidence was needed to prove the efficiency of TECH Support, as the test sample was relatively small. However, help was offered to design and implement new interventions to confirm the findings.

Conclusion

Hospital readmission of patients with CHF is found to be dependent on health literacy. Nurses play a central role in providing relevant education to patients with increased risks of CHF. The present project offers the TECH Support intervention that was proven to be a cost-efficient method of reducing hospital readmission among older adults diagnosed with heart failure. Even though the results of the project show a 60% decrease in readmission rates, the test sample may be too small to account for the universality of the effect. However, the current studies examined in the paper confirm the credibility of the achieved results.

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References

Cajita, M., Cajita, T., & Han, H. (2016). Health literacy and heart failure. The Journal of Cardiovascular Nursing, 31(2), 121-130. Web.

Cox, S. (2017). Congestive heart failure. In A. Shanan, J. Pierce, & T. Shearer (Eds.), Hospice and palliative care for companion animals: Principles and practice (pp. 109-114). Hoboken, NJ: John Wiley & Sons.

Hasanpour-Dehkordi, A., Khaledi-Far, A., Khaledi-Far, B., & Salehi-Tali, S. (2016). The effect of family training and support on the quality of life and cost of hospital readmissions in congestive heart failure patients in Iran. Applied Nursing Research, 31, 165-169. Web.

Haun, J., Patel, N., French, D., Campbell, R., Bradham, D., & Lapcevic, W. (2015). Association between health literacy and medical care costs in an integrated healthcare system: A regional population based study. BMC Health Services Research, 15(1). Web.

Howie-Esquivel, J., Carroll, M., Brinker, E., Kao, H., Pantilat, S., Rago, K., & De Marco, T. (2015). A strategy to reduce heart failure readmissions and inpatient costs. Cardiology Research, 6(1), 201-208. Web.

Hughes, L., & Witham, M. (2018). Causes and correlates of 30 day and 180 day readmission following discharge from a Medicine for the Elderly Rehabilitation unit. BMC Geriatrics, 18(1). Web.

Ziaeian, B., & Fonarow, G. (2016). The prevention of hospital readmissions in heart failure. Progress in Cardiovascular Diseases, 58(4), 379-385. Web.

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