The many variations of CHF discharge instructions

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Best practice

When patients come into the hospital with an illness or health problem, staff members must do all they can to help patients improve during their stay. Staff members must also ensure that patients take care of themselves upon leaving to prevent a rehospitalization.

Congestive heart failure (CHF) is a health problem that requires special care and follow-up for patients.

Dickinson County Healthcare System (DCHS) in Iron Mountain, MI, and Smithville (TX) Regional Hospital (SRH) each decided to revamp their CHF discharge instructions to help avoid CHF patient readmission. As a result, both facilities saw a drop in their readmission rates and a general acceptance of discharge instructions from patients and staff members alike.

Common ground shared between facilities

Along with preventing readmission, both facilities wanted to improve their compliance with CMS requirements and make improvements to their quality initiatives.

However, prior to each facility deciding to revamp their CHF discharge instructions, Jeanette Parent, RN, nursing education coordinator at DCHS, and Julie Miller, RN, quality director at SRH, each received information to help them take that initial step toward developing the instructions.

Parent says the review analyst team at DCHS found that the facility was consistently failing the written discharge part of Core Measure Standard #1 for CHF.

Based on this finding, Parent and other staff members at DCHS set out to develop the discharge instructions to help comply with this standard.

Meanwhile, Miller says her facility didn’t necessarily see an increase of readmissions, but it did see a potential for increase based on evidence-based standards referenced by CMS’ Quality Initiatives.

“We developed the patient teaching sheet to assist us in making sure the patients got the information they needed to manage their disease after discharge,” says Miller. “One of the quality initiatives was to prevent readmission.”

SRH provides weight monitoring calendar

Although the CHF instruction sheets at both facilities are designed to educate patients as they leave the facility as well as prevent readmission, there are some differences.

SRH’s CHF instruction sheet was developed in 2005, right as Miller came on board in the quality management department.

One of the main reasons for developing the instruction sheets was the fact that the facility did not have electronic medical records.

“Nurses would forget to document whether or not they had educated the patient on weight monitoring and basic follow-up information,” says Miller.

The two-page Patient Information on Heart Failure document (see p. 6) was developed using resources from the TMF Health Quality Institute, formally known as the Texas Medical Foundation.

On the first page is a list of symptoms to watch for when patients return home. These symptoms may indicate that a patient’s CHF is worsening and that he or she should contact his or her physician.

At the bottom of the first page is a line for the patient to sign and date. Once the patient has signed, one copy goes into the patient’s records and the other is sent home with the patient.

The second page of the CHF instructions focuses on weight monitoring.

“Due to the fact that CHF can cause the patient’s body to retain water, it is important that the patient weighs themselves regularly,” says Miller.

The instruction sheet provides three calendar sheets where patients can monitor their weight and get in the habit of doing it every day.

Along with the CHF discharge instructions, patients were also given instructions on when to follow up with their doctor. The follow-up appointment varied, depending on the individual patient. It could range anywhere from three to seven days.

DCHS’ checklist and follow-up phone calls

At DCHS, the CHF discharge instructions are slightly different.

DCHS’ heart failure document was developed in 2004 after the facility failed Core Measure Standard #1 for CHF, which addresses discharge instructions and patient education.

DCHS felt that nurses were educating patients but failed to document their teaching.

Parent and a team consisting of the review analyst, the manager of medical and ICU, representatives from nursing education, and the case manager, devised the Heart Failure document that is distributed to CHF patients.

“We give any inpatient that has the diagnosis of CHF as their principal diagnosis and/or has a secondary diagnosis a teaching sheet for CHF,” says Parent.

The one-page teaching sheet lists the definition and symptoms of CHF as well as general information about the disease.

The general information portion of the teaching sheet includes instructions for patients to follow when they return home. Some of these instructions ask CHF discharge patients to:

  • Weigh themselves daily in the morning, on the same scale, wearing similar clothing
  • Avoid drinking softened water—salt is used to soften it
  • Limit intake of caffeine and alcohol
  • Keep regular physician appointments
  • Check pulse prior to and after taking medications such as Digoxin/Lanoxin

Parent says even after DCHS initiated this teaching sheet, it was still seeing repeat readmissions.

“The case manager noticed that we were seeing one or two patients with three to four admissions over several weeks due to noncompliance,” she says.

To help prevent this from happening, the case manager worked with the cardiac rehabilitation manager to provide ongoing education for patients discharged with CHF.

As part of this ongoing education, an RN from the cardiac rehabilitation center was tasked with calling each patient at home. The RN would ask patients whether they were taking their medication, what their weight was, and how they were feeling. The RN would also send educational material to CHF patients every week for six weeks.

Physicians were somewhat reluctant in the beginning because they thought they were giving out too much information.

“In the end, we were able to sell our views,” says Parent.

Results and acceptance

After implementation, SRH patients were receptive to being educated on their disease, and the doctors found the CHF discharge information to be helpful because patients were ready with the information, says Miller.

The CHF discharge information has been so well received that SRH has begun development of similar patient education forms for patients diagnosed with pneumonia.

At DCHS, patients and their families really liked the instruction sheet because they were able to return to it as a reference, says Parent.

When asked what they would do differently, Parent and Miller both said they would get the nurses more involved next time around.

“Nurses can bring you real-life experiences,” says Miller. “They have worked with the patients and can tell us what works best for them.”

“Include your staff more; once they have an understanding of why we need them to review yet another piece of paper with patients, they jump on board,” Parent says.