Prevention of Heart Failure Hospital Readmissions

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Abstract

  • Heart failure (HF) is incurable.
  • Affects over 5 million people.
  • Costs 1.7 billion dollars annually.
  • High rates of readmissions: complex care.
  • Inadequate patient education.
  • High incidence among African Americans.
  • Interventions aimed at reducing readmissions.
  • Implementation of a specialized nurse case manager.

Abstract

Introduction

  • Heart failure:
    • Serious health concern.
    • High prevalence among aging population.
  • Complex management: affects 5 million people.
  • High hospital readmission rates.
  • In 2006:
    • More than 1 million admissions.
    • 24.2% readmitted within a month.
  • Higher prevalence among African Americans: 50%.
  • Prevalence differences:
    • The elderly between 75 and 84 years.
    • 20% more black men.
    • 27% more black women.
  • Possibility of development higher in younger people:
    • Risk 20 times higher among African Americans.
    • Higher mortality rates.
    • 45% greater death risk among African Americans.
  • Improvement of patient care imperative.
  • Areas of focus:
    • Anatomical/physiological/epidemiological issues.
    • Analytical questions of healthcare costs.
    • Prevalence among populations.
    • Causes of care disparity.

Introduction

Introduction

Structure of the Heart

  • Heart plays many functions:
    • Pumps blood to cells.
    • Provide energy, nourishment, and normal functioning.
  • 4 chambers: atria and ventricles.
  • Atria: upper chambers.
  • Ventricles: lower chambers.
  • Heart function involves organized contractions.

Structure of the Heart

Heart Failure Definition

  • Heart failure: weak muscles malfunction.
  • Functional, structural or biological impairment.
  • Hearts inability to deliver adequate blood.
  • Symptoms of HF:
    • Fatigue.
    • Water retention.
    • Edema.
    • Shortness of breath.
    • Exercise intolerance.
    • Fluid retention.

Heart Failure Definition

Diagnosis

  • A difficult process.
  • Involves clinical diagnosis and examination.
  • HF:
    • impairment of systolic ventricular function.
    • Damage to heart valves or pericardium.
  • Stages of heart failure:
    • Stage A: high risk.
    • Stage B: structural heart abnormalities.
    • Stage C:abromalities and symptoms.
    • Stage D: symptoms resistant to treatment.

Diagnosis

Risk Factors

  • Double risk among African Americans.
  • Cause of higher prevalence:
    • Inadequate education.
    • Financial strain.
    • Inadequate housing.
    • Lower annual incomes.
  • Lack of primary care providers.
  • Poor insurance status.
  • Disparity in delivery and access to care.
  • History of hypertension, obesity, and diabetes.
  • Racial and ethnic equality in clinical trials.

Risk Factors

Living with Heart Failure

  • Heart failure is incurable.
  • Impaired functioning, medical crises, and hospitalizations.
  • Functional losses and increased dependency.
  • Increased difficulty of management.
  • Successful treatment involves cooperation.
  • AHA treatment recommendations:
    • Lifestyle changes:
      • Diet modification.
      • Alcohol avoidance.
      • Cessation of tobacco use.
    • Medical management: pharmaceuticals.
    • Implantable medical devices.

Living with Heart Failure

Heart Failure Cost

  • Highest HF readmissions.
  • Largest total cost: $1.7 billion.
  • CMS penalty: $428 million.
  • HF readmission cases:
    • Health care quality challenge.
    • Health care cost issue.
  • Utility of treatment: tension regarding HF:
    • Chronic deteriorating condition.
    • Terminal illness.
  • Aggressive care is more costly.
  • Medical management: 10 medications.
  • Advanced technologies.
  • WHO recommendation:
  • Early palliative care.
  • The NMAHFCP 2013 findings:
    • African Americans ignore treatment guidelines.
    • Need to track HF disparities.
  • Mitigation of health care inequality.
  • Equality critical for medical decisions.

Heart Failure Cost

Heart Failure Cost cntnd

Change from Traditional Inpatient Care

  • HF care is complex.
  • Traditional inpatient care processes are inadequate.
  • Post-discharge needs ignored.
  • Minimal patient teaching.
  • High readmissions signify ineffective methods.
  • Shift focus to long-term outcomes.
  • Emphasis on self-care management.
  • Implementation of nurse case managers.
  • HF case management:
    • Patients physician.
    • Physical therapist.
    • Dietician.
    • Pharmacist.
    • Cardiologist.
    • Social worker.
  • A multidisciplinary approach.
  • Individualized treatment.

Change from Traditional Inpatient Care

Change from Traditional Inpatient Care

Inpatient Education

  • Implemented by nurse case manager.
  • Conducted throughout hospitalization and discharge.
  • Enhanced communication with health care team.
  • Medication teaching:
    • Reduces readmission rates.
    • Compliance with medications.
    • Improved clinical outcomes.
  • Patient understanding of medication regimen.

Inpatient Education

Implantable Devices

  • Implantable cardio defibrillators prolong survival.
  • Implantable devices benefits:
    • 37% reduction in hospitalizations.
    • 60% drop in patient mortality.
    • The use of less medication.
  • Risk involvement.
  • Individualized disease management.

Implantable Devices

Diet

  • Appropriate diet and nutrition education.
  • Diet indiscretions worsens HF.
  • A low sodium diet.
  • Western diet is a challenge.
  • Control of intravascular fluid volume.

Diet

Lifestyle Changes

  • Lifestyle improvement education.
  • Abstinence or avoidance of alcohol:
    • Induced cardiomyopathy.
  • Controlled fluid intake:
    • 1.5-2.0 liters daily.
    • Relieve symptoms of congestion.
  • Involvement in regular exercise:
    • Emotional well being.
    • Increase breathing capacity.
  • Smoking cessation:
    • Decrease breathlessness.

Lifestyle Changes

Discharge Planning

  • 30-90 days post-discharge critical.
  • Impact of Cognitive and social issues.
  • Follow up appointment reduces readmission.
  • Clear medication regimen instructions.
  • Communication:
    • 48 hours after discharge.
    • Biweekly for 3 months after discharge.
  • Education of care providers.
  • Importance of home support.

Discharge Planning

Follow up Care: Patient Education

  • Importance of checking daily weight.
    • Signs of excessive weight gain.
    • Risks of kidney failure.
  • Home health nurse visits:
    • Verification of patient medication adherence.
    • Weight patterns.
  • Importance of individualized treatment plans.
  • Public health model for African Americans:
    • Health education.
    • Primary prevention.
    • Risk assessment.
    • Improved access to care.
    • Use evidence-based therapies.
  • Fulfillment of patients essential needs:
    • Income concerns.
    • Adequate housing.
    • Access to medications.

Follow up Care: Patient Education

Conclusion

  • HF is costly to the healthcare system.
  • Care aggressiveness creates tension.
  • How should HF be classified?
    • A chronic deteriorating disease.
    • A terminal illness.
  • Need for racial and ethnic equality.
  • Health care reforms.
  • Importance of medical management.
  • Education and coordination of patient care.
  • The roles of specialized HF nurse care managers:
    • Patient/caregiver disease education.
    • Medication compliance.
    • Clos follow up.
    • Patient callbacks.
  • Reduction of readmissions:
    • Intensive inpatient education.
    • Discharge planning.
    • Follow up care.
  • Quality improvement programs.

Conclusion

Conclusion

References

American Heart Association (2018). About Heart Failure. Web.

Brake, R., & Jones, I. (2017). Chronic heart failure part 2: Treatment and management. Nursing Standard (royal College of Nursing (Great Britain): 1987,31(20), 53-63. doi:10.7748/ns.2017.e10762

Chandrasekaran, B., & Cowburn, P. (2010). Heart failure: The challenge of selecting patients for implantable cardioverter defibrillator therapy. Expert Review of Medical Devices,7(4), 461-7. doi:10.1586/erd.10.18

David, D., Howard, E., Dalton, J., & Britting, L. (2018). Self-care in heart failure hospital discharge instructions differences between nurse practitioner and physician providers. The Journal for Nurse Practitioners,14(1), 18-25. doi:10.1016/j.nurpra.2017.09.013

DeFelice, P., Masucci, M., McLoughlin, J., Salvatore, S., Shane, M., & Wong, D. (2010). Congestive heart failure: redefining health care nursing. Journal of Continuing Education in Nursing, 41(9), 390-1. Retrieved from CINAHL Plus with Full Text Database.

Fleming, L., Gavin, M., Piatkowski, G., Chang, J., & Mukamal, K. (2014). Derivation and validation of a 30-day heart failure readmission model. The American Journal of Cardiology, 114(9), 1379-82. doi:10.1016/j.amjcard.2014.07.071

Gardenier, D., Valles-Gutierrez, L., & Ballard-Hernandez, J. (2018). Do discharge instructions make a difference in patients with heart failure? The Journal for Nurse Practitioners,14(10), 708-709. doi:10.1016/j.nurpra.2018.07.001

Glippatos, G., & Zannad, F. (2007). An introduction to acute heart failure syndromes: Definition and classification. Heart Failure Reviews,12(2), 87-90. doi:10.1007/s10741-007-9008-3

Mitchell, J. E., Ferdinand, K. C., Watson, K. E., Wenger, N. K., Watkins, L. O., Flack, J. M., . . . Wright, J. T. (2011). Treatment of heart failure in African Americans A call to action. Journal of the National Medical Association, 103(2), 86-98. Web.

Panagiotis Georgoulias. (2016). FRONTIERS IN HEART FAILURE : Frontiers in Heart Failure (volume 1). Bentham Science Publishers Ltd.

Rothberg, M., MD, MPH, & Sivalingam, S., MD. (2010). The new heart failure diet: Less salt restriction, more micronutrients. Journal of General Internal Medicine,25(10), 1136-1137. doi:10.1007/s11606-010-1254- 8

Schwarz, E. R., Philip, K. J., Simsir, S. A., Czer, L., Trento, A., Finder, S. G., & Cleenewerck, L. A. (2011). Maximal care considerations when treating patients with end-stage heart failure: Ethical and procedural quandaries in management of the very sick. Journal of Religion and Health, 50(4), 872-9.

Stocker, R., Close, H., Hancock, H., & Hungin, A. (2017). Should heart failure be regarded as a terminal illness requiring palliative care? A study of heart failure patients, carers and clinicians understanding of heart failure prognosis and its management. Bmj Supportive & Palliative Care, 7(4), 464-469. doi:10.1136/bmjspcare-2016-0012

Vaccarino, V., Gahbauer, E., Kasl, S., Charpentier, P., Acampora, D., & Krumholz, H. (2002). Differences between African Americans and Whites in the outcome of heart failure: Evidence for a greater functional decline in African Americans. American Heart Journal,143(6), 1058-67.

Vidic, A., Chibnall, J. T., & Hauptman, P. J. (2015). Heart failure is a major contributor to hospital readmission penalties. Journal of cardiac failure, 21(2), 134-137.

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