Master School International Seminar 3: The role of nurses in the management of patients with congestive heart failure: prevention of early readmission
The prevalence of congestive heart failure (CHF) is between 1 to 2 % in the general population, but this much higher in elderly persons (1 – 3). The prognosis of CHF is difficult to estimate.
In case of congestive heart failure, one can expect a survival one to five years, but there is a continuous risk for sudden death (4). Moreover, symptoms and signs significantly reduce the quality of life (2) and increase health care costs (4). Understanding CHF is also more difficult in patients with frailty and comorbid conditions. These patient groups are heterogeneous and there is a serious gap in the knowledge of their management (4). Readmission within thirty days after discharge can be up to 20 – 30 % (3 – 6) and within six months, this can be even 50 % (7).
A high readmission rate for CHF is a serious problem and can serve as measure for quality of care in this respect (4). Risk factors for early readmission are increasing age, living alone, sedentary life style, comorbid conditions (8) while timely and adequate outpatient care and management could be protective (7).
The most common reasons for readmissions are a relapse of CHF, acute renal failure and pneumonia (5). To make matters worse, CHF tends to worsen with each readmission. To address this problem, following questions arise.
Are there markers for readmission and are they useful for a bedside approach?
Does self-management by nurse-led clinic and regular follow-up improve outcome?
Do educational level and health literacy matter?
The method involves the exploration of a sample of the literature between 2014 and 2019 for real-life experiences. This includes aspects during the hospital stay as well as after discharge. Large US and Swedish surveys as well as a smaller Chinese and Spanish example show important clues. Five more reviews give some additional theoretical insights.
In a cross sectional examination of three US hospitals, including over 160,000 heart failure patients, hospital characteristics are scrutinized for several aspects: technical facilities, number of patients treated, the ratio of revenue and expense and teaching status (5). An effect is observable for the environmental characteristics for nursing. These include 1) investment in nursing staff development with the ability to discern and attend to complex need for care, 2) adequate management and resources at hospital and at ward level, 3) the working conditions, especially with respect to the patients/nurse ratio, and 4) availability of time (5). Talking / comforting, care planning and counselling are the highest percentage of missed care in patients with heart failure.
These numbers increase in hospitals with a poor working environment, but these figures remain high, even in good working conditions. Especially, the missed care has an effect on the outcome. The odds for readmission increased with 12 % for missed treatments and procedures, 6 % with missed coordination with 4 % for missed counselling and documentation with 3 % for missed care planning, especially when this missing took place during the last day of stay, when most questions arise for the patient (5).
A small Chinese randomized trial divided patients in an intervention and a control group. The intervention group underwent two sessions of education of one hour during hospital stay, the last just before discharge. This included teaching of skills (self-monitoring and management, journal-keeping, medication and diet compliance), counseling for associated mental conditions but also assessment of knowledge (understanding of CHF) and enlisting relatives to provide psychological and social support. A nurse provided for post-discharge care every four weeks. This included education as well as updating information concerning self-management (medication, diet, symptoms and signs). A physician examined the patient every eight weeks. This approach resulted in a reduction of readmission within the first year after discharge (8).
A large Swedish nationwide registry (Swede HF) showed that only 39 % of the patients are referred to a nurse-led heart failure clinic. These patients had more severe CHF, more CHF medication but lower comorbid conditions. The nurses provided for education, psychological support and assessment of mental well-being and if necessary adapted treatment under supervision of a physician. This approach reduced mortality but not re-hospitalization: patients with worsening CHF were identified and referred to the hospital in an earlier stage (3).
A small Spanish cross-sectional study included randomly selected elderly patients from primary health care centers (PHC). These had a good exercise tolerance and low health literacy index. PHC care givers played an important role in identifying patients with poor self-management skills (low educational level, cognitive impairment, and high age) and bidirectional communication with hospitals. There was less endorsement of daily weighing (11 %) and contacting physicians with increasing weight (23 %) and regular exercise. The interrelation between CHF and cognitive impairment and low health literacy was an important aspect, since the latter made it more difficult to recognize symptoms of deteriorating CHF. Moreover, in contrast to dyspnea, patients tolerated all too easy weight gain, edema and fatigue. Cognitive impairment and anxiety worsened this behavior. This led to a decrease in recognition of symptoms, less adherence to medication and dietary restrictions.
Home visits by specialized heart failure nurses could help patients in education and self-management and reinforce good practice with respect adherence to medication, dietary restrictions, recognizing weight gain, edema, fatigue, regular exercise and seeking timely doctor’s help (2).
Two types of intervention are helpful in exploring maladaptive behaviors in patients with CHF. First, motivational interviewing can improve self-care in patients with CHF, but is not necessarily sustainable. Collaboration, empathy and enhancement of self-efficacy are its hallmarks. Second, through cognitive behavioral intervention a patient is able to recognize irrational thoughts and misconceptions in interpreting adverse events. This approach shows effectiveness in CHF patients with comorbid conditions and seems more sustainable.
Both techniques are synergistic (6). In a large sample of Canadian nursing home residents with CHF had higher rates of hospitalization and death. Remarkably, the relative impact of CHF was smallest in patients with the highest degree of instability. This instability is a composite of reversible and irreversible conditions. It illustrates the importance of these conditions because they dilute the effect of CHF on the outcome (1).
The natural history of CHF has three phases (4). First, there is the acute phase with a transition. A chronic, more or less stable period follows this acute phase. However, there is progression of the disease. At last, this ends with end-stage heart failure, for which only symptomatic and palliative treatment is possible (9). During this transition, the patient experiences a vulnerable episode during which the risk for early readmission is high. Appropriate measures could decrease this risk for readmission. These measures are subdivided in pre and post-discharge factors.
There is an association between missed nursing care and early readmissions for heart failure, which largely depends on the quality of the environment in which nurses have to work. This quality includes collegial inter-professional relationships, investment, investment in the development of staff and an adequate management (5). Even a small cohort of patients could demonstrate a clear effect on an in-hospital program of education (8).These factors allow a more effective care for patients. The reduction in early readmission of heart failure patients compensates largely the costs for increase in investment in nursing care.
In remote areas, an education led by dedicated nurses clearly leads to an improved self-management and hence to improved clinical outcome (8). Results of the Spanish experience confirm these finding and stresses the interrelation between CHF and cognitive impairment and low health literacy. The latter causes increased vulnerability in patients with CHF, since they are less able to recognize symptoms and to react in an appropriate way.
Home visits by specialized heart failure nurses can help patients in education and self-management and reinforce good practice with respect adherence to medication, dietary restrictions, recognizing weight gain, edema, fatigue, regular exercise and seeking timely doctor’s help (2). Motivational interviewing (as improvement of communication style) and cognitive behavioral intervention such as setting up environmental reminders and addressing misconceptions (for increasing problem solving skills) could improve self-care in heart failure patients if these are applied synergistically (6)
The course of CHF is one of repeated hospitalization, progressive decline, increasing frailty and complexity and finally, death (1). How to approach the last phase of CHF is also debatable. Because of the continuous risk for sudden death, its course is unpredictable. Recognizing and planning end of life (EOL) and palliative care situations is difficult. Early referral could improve the quality of life in this period.
Although palliative care has been designed for cancer patients, it could also be used for patients with end-stage CHF. Misconceptions, with its consequences (perception of palliation as a treatment failure, lack of funding, information, access and trained staff), need to be overcome. Furthermore, there are legal issues, which need addressing. These include timing of deactivation of an ICD or LVAD, the role of morphine in symptom management, timing of admission of patients (only at imminent death or earlier), the role of life prolonging medication in this period, and finally the role of general practitioners, cardiologist, and specialized nurses (9).
Missed care plays an important role in the high re-admission rate for CHF. An adequate in-hospital care and post-discharge follow-up can prevent early readmission partly. Patient education and self-management are an important part in this respect. Cognitive impairment and other comorbid conditions play an important and negative role in recognizing signs of deterioration. CHF patients constitute a very heterogeneous group, making it difficult to find other markers for early readmission. The course of CHF is difficult to predict, which makes palliative and end-of-life care more complex.
1) Heckman GA, Hirxdes JO, Hébert PC, Morinville A, Amaral ACKB, Costa A. & McKelvie RS. Predicting Future Health Transitions among Newly Admitted Nursing Home Residents with Heart Failure. JAMDA 2019; 20: 438 – 443.
2) Santesmases-Masana R., Gonzalez-de Paz L., Hernandez-Martinez-Esparza E., Kostov B. & Navarro-Rubio MD. Self-Care Practices of Primary Health Care Patients Diagnosed with Chronic Heart Failure: A Cross-Sectional Survey. Int J. Environmental Health 2019;16:1625 -1640.
3) Savarese G., Lund LH, Dahlström, U. & Strömberg, A. Nurse-Led Heart Failure Clinics Are Associated with Reduced Mortality but not Heart Failure Hospitalization.
4) Iyngkaran P., Liew D., Neil C., Driscoll A., Marwick TH. & Hare DL. Moving from Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients with Multiple Comorbidities and Older Age. Clin. Med. Insights 2018; 12:1 -13.
5) Carthon JMB, Lasater KB, Sloane DM & Kutney-Lee A. The quality of hospital work environments and missing nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals. BMJ Qual Saf; 2015:24(4):255-263.
6) Chew HSJ, Cheng HY & Chair SY. The suitability of motivational interviewing versus cognitive behavioral interventions on improving self-care in patients with heart failure: A literature review and discussion paper. Appl Nurs Res 2019; 45:17 – 22.
7) Wood RL, Migliore LA, Nasshan SJ, Mirghani SR & Contasi AC. Confronting Challenges in Reducing Heart Failure 30-Day Readmissions: Lessons Learned with Implications for Evidence-Based Practice. World Views on Evidence-Based Nursing 2019;16 (1):43 – 50.
8) Cui X, Zhou X, Ma LI, Sun TW & Bishop L. A nurse-led structural education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: randomized controlled trial in China. Rural and Remote Health 2019; 19: 5270 doi.org/10.22605/RRH5270.
9) Singh GK, Davidson PM, Macdonald PS. & Newton PJ. The Perspectives of Health Care Professionals on Providing End of Life Care and Palliative Care for Patients with Chronic Heart Failure: An Integrative Review. Heart, Lung & Circ 2019; 28:539 – 552.