UOA Heart Rate Deflection Point & Ventilatory Threshold Paper I uploaded two files explaining how this paper must be completed. I also uploaded the article that will be used to complete this paper. Answer the questions below in a few paragraphs regard the question and article referenced
Identify support from the
articles for the
problem/PICO question.
Identify and describe
interventions related to
problem/PICO question
found in the articles.
Include impact of identified
interventions on nursing
practice.
State proposed
interventions to resolve the
identified problem.
Suggest methods to evaluate
the proposed interventions.
P – heart failure patients
I – multidisciplinary educational approach
C – educational methods utilized for inpatient & outpatient CHF teaching
O – identify educational approaches that help in prevention of readmissions of heart failure
patients.
Question:
Which educational techniques or strategies most effectively prevent hospital
readmissions in patients with heart failure?
Ryan, C. J., Bierle, R. S., & Vuckovic, K. M. (January 01, 2019). The Three Rs for Preventing
Heart Failure Readmission: Review, Reassess, and Reeducate. Critical Care Nurse, 39(2), 85-93.
Title:
The Three Rs for Preventing Heart Failure Readmission: Review,
Reassess, and Reeducate. By: Ryan, Catherine J., Bierle, Rebecca
(Schuetz), Vuckovic, Karen M., Critical Care Nurse, 02795442,
Apr2019, Vol. 39, Issue 2
Database:
CINAHL Plus with Full Text
The Three Rs for Preventing Heart Failure
Readmission: Review, Reassess, and
Reeducate
Listen
American Accent
Despite improvements in heart failure therapies, hospitalization readmission rates remain high.
Nationally, increasing attention has been directed toward reducing readmission rates and thus
identifying patients with the highest risk for readmission. This article summarizes the evidence
related to decreasing readmission for patients with heart failure within 30 days after discharge,
focusing on the acute setting. Each patient requires an individualized plan for successful
transition from hospital to home and preventing readmission. Nurses must review the patient’s
current plan of care and adherence to it and look for clues to failure of the plan that could lead to
readmission to the hospital. In addition, nurses must reassess the current plan with the patient
and family to ensure that the plan continues to meet the patient’s needs. Finally, nurses must
continually reeducate patients about their plan of care, their plan for self-management, and
strategies to prevent hospital readmission for heart failure.
Heart failure (HF) is a chronic disease that affects 6.5 million people in the United States,
with 960 000 incident cases per year. The prevalence and 5-year survival continue to
increase. Each year, more than 1 million people are hospitalized with HF.[ 1] Despite
improvements in HF therapies, hospital readmission rates remain high.[ 2] In 2009, the US
Centers for Medicare & Medicaid Services (CMS) began public reporting of all-cause
readmission rates after an index HF hospitalization; CMS subsequently financially penalized
hospitals with high readmission rates during the first 30 days after discharge. Nationally,
increasing attention has been directed toward reducing readmissions and thus identifying
patients with the highest risk for readmission. Although recent reviews of mortality rates for
patients with HF show an increase in mortality as 30-day readmission rates have declined,[ 3]
we are focusing on treatment strategies to reduce readmissions because that is the current
CMS policy.
Many of the existing readmission data have been derived from registries, databases generated
from randomized clinical trials, and Medicare administrative claims. Often, readmissions have
been categorized as preventable or unpreventable. In other cases, reasons for readmission
have been categorized as clinical, behavioral, and patient-centric, with recognition that the
responsibility for readmission may reside with the patient, provider, hospital system, or any
combination thereof (Table 1).
Studies have shown that a single intervention may not be sufficient to address the multiple
needs of patients with HF and that the transition of care should be individualized and
multifaceted to achieve additive and synergistic effects. Readmission may reflect a failure of the
discharge process; thus, discharge planning should start at the time of admission. Nurses are
ideally suited to reviewing the current plan of care, reassessing and revising the plan of care
with the HF treatment team, and reeducating the patient and family about self-care to reduce the
risk of readmission (see Figure). Multiple strategies have been reported for decreasing
readmissions. This article summarizes the evidence related to decreasing readmission for
patients with HF within 30 days after discharge, focusing on clinical, psychosocial, and systemsbased factors in the acute setting.
Clinical Factors
Self-management
Self-management is essential to optimizing outcomes and preventing hospitalizations. To
engage in self-management, patients and their families or caregivers need to acquire knowledge
and skills. In a qualitative study designed to explore the root cause of HF readmission, Retrum
et al[12] discovered 5 patient-identified factors as reasons for readmission: distressing
symptoms, unavoidable illness progression, psychosocial factors, imperfect self-care, and health
system failures. In a recent study, patients reported that they believed their HF admission could
have been prevented if they had more knowledge and adhered to their diet.[13] Bradley et al[11]
surveyed hospitals successful at reducing readmissions that were enrolled in the Hospital to
Home initiative and created a summary of 10 key practices. Of the 10 practices, 3 centered on
medication management. Education about the purposes of each medication, changes in dose or
frequency, which to stop, which to start, and how to take them correctly was identified as
essential to self-management. Nurses in the hospital have numerous opportunities to make an
impact on self-management by reviewing medication and other self-management skills with
patients and their families. As the patient’s condition or life situation changes, or HF progresses,
nurses may be the first to identify such shifts and help the patient acquire new skills and
knowledge to adapt.
Patient Education
Current HF guidelines recommend that patients with HF receive “specific education to facilitate
self-care.”[14](p263) All patients with HF need to know how to monitor and report their
symptoms and weight fluctuations, restrict sodium intake, adhere to their prescribed medication
regimens, and stay physically active (Table 2). A systematic review of 35 educational
intervention studies found that knowledge, self-monitoring, medication adherence, time to
hospitalization, and days in the hospital improved with education.[18] Educating patients before
discharge has been shown to reduce readmissions, and poor adherence to discharge
instructions can lead to worsening HF and readmissions.[15] Nurses are critical to the success
of patient education; however, the recommended 1 hour of comprehensive patient education
may be difficult to incorporate into practice.[16],[19] The American Heart Association (AHA) GetWith-The-Guidelines-Heart Failure program is a hospital-based quality improvement program to
promote the use of evidence-based guidelines when caring for patients with HF. The AHA
provides a tool that includes patient education in the form of a discharge checklist, which is
available at www.heart.org/heartorg/Professional/TargetHFStroke/TargetHF/Target-HFStrategies-and-Clinical-Tools%5fUCM%5f432444%5fArticle.jsp#.WnDpEK6nHcs. A variety of
educational methods may be used to best meet the patient’s needs, keeping in mind that patient
education should be culturally appropriate. Discharge planning and education should reflect a
multidisciplinary team approach and may include cardiologists, pharmacists, social workers,
physical and occupational therapists, and discharge planners.[15] However, nurses play a
pivotal role in discharge education, as they are often the ones providing patients with the
discharge instructions. One efficient way to teach patients and increase their knowledge is the
teach-back method. This method is an effective way to deliver HF education and, when bundled
with prompt follow-up appointments and telephone calls, reduces 30-day readmissions.[20],[21]
A tool kit for the teach-back method provided by the Agency for Healthcare Research and
Quality is available at www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacy -toolkit/healthlittoolkit2-tool5.html. Instructional videos for the teach-back
method can be found on the American Association of Heart Failure Nurses website at
www.aahfn.org.
Biomarkers
Routine laboratory tests of hemoglobin, electrolytes, and renal and liver function are helpful to
discern end-organ dysfunction in advanced HF. Natriuretic peptides (B-type [BNP] and Nterminal pro [NT-proBNP]) and cardiac troponin I (cTnI) may be of value to predict outcomes,
including readmission. Patients with a predischarge BNP of 430 pg/mL or less are less likely to
be readmitted within 30 days.[22] Predischarge NT-proBNP is also more strongly associated
with outcomes than NT-proBNP level at admission.[ 5],[ 9] Bettencourt et al[ 9] found that a 30%
reduction in NT-proBNP was associated with a higher risk of death or readmission. A higher
BNP measured at discharge may serve as a prompt for an earlier clinic appointment or
discharge telephone call to assess the patient’s condition and help prevent readmission.
Measuring and monitoring cardiac troponin levels are important as elevations may indicate
myocardial ischemia and necrosis even in the absence of pain.
Cardiac troponin levels (cTnI, cTnT) add prognostic information to that obtained from other
clinical data. Elevations in cTnI and cTnT both correlate with a poor prognosis and increased
risk of mortality, but current evidence indicates that elevated cardiac troponin levels do not
predict 30-day readmission rates.[22] However, measuring and monitoring cardiac troponin
levels are important, especially in the acute setting, as elevations may indicate myocardial
ischemia and necrosis even in the absence of chest pain.[17]
The New York Heart Association (NYHA) class is an indirect interpretation of patients’
symptoms, history, and results of cardiac testing that is generally assessed and assigned by
clinicians. Although it is an imperfect measure, several studies have shown that NYHA class is a
predictor of mortality and readmission for HF patients.[23]–[25] Holland et al[24] allowed patients
with both reduced and preserved ejection fraction HF to self-assign their NYHA class and found
that those with a higher class (III and IV) had more frequent hospital readmissions than patients
with baseline classes I and II (who had a similar incidence of readmission). Ahmed et al[23]
studied only patients with an ejection fraction greater than 45%. They reported that ambulatory
patients with NYHA class III and IV HF and preserved systolic function also had higher
readmission rates. Both of these studies indicated that multiple factors other than NYHA class
directly affect risk for readmission.
Comorbidities
The recently released American College of Cardiology (ACC)/AHA/Heart Failure Society of
America HF focused update includes recommendations for addressing important comorbidities
in HF patients.[ 5] The update notes that anemia may be independently associated with HF
disease severity and is associated with decreased exercise capacity. Therefore, the update
recommended that patients with NYHA class II or III HF who also have iron deficiency (ferritin <
100 ng/mL or 100-300 ng/mL if transferrin saturation is < 20%) receive intravenous iron
replacement therapy. These new recommendations also include initiating therapies that maintain
a systolic blood pressure of 130 mm Hg for patients with stage C reduced and preserved
ejection fraction HF, noting that blood pressure control is associated with fewer adverse
cardiovascular events. Lastly, the recommendations specify that patients with NYHA class II to
IV HF and sleep-disordered breathing or excessive daytime sleepiness have a formal sleep
assessment to determine whether they are experiencing obstructive or central sleep apnea.
Continuous positive airway pressure may be used to improve sleep quality and decrease
daytime sleepiness.[ 5]
Psychosocial Factors
Health-Related Quality of Life
Low health-related quality of life (HRQOL) predicts readmissions in patients with HF. As
mentioned in the 2013 ACC/AHA Guideline for the Management of Heart Failure, lack of
improvement in HRQOL after discharge is a powerful predictor of readmission.[14]
Clinicians often rely on patients' subjective assessment of their functional classification to guide
treatment and management of their HF. Stull et al[26] found that HRQOL was an independent
and significant predictor of HF-related hospitalizations across all age groups in patients with HF
with reduced ejection fraction, compared with traditional clinical indicators such as NYHA
functional class, ejection fraction, blood urea nitrogen, creatinine, or comorbidities. Previous
studies have aimed to standardize the evaluation of health status from the patient's perspective
to aid in clinical management.[27] Patient-reported outcomes (PROs) are standardized tools that
can provide information on patients' health status, including HRQOL. One potential way to
incorporate HRQOL is to use a PRO tool such as the Minnesota Living with Heart Failure
Questionnaire. Heart failure–specific PRO tools have been increasingly used in multiple
settings, including discharge follow-up visits, routine outpatient appointments, and
hospitalizations, to guide treatment.[28]
Depression
Depression is more common in people with HF than in the general population and is associated
with all-cause readmissions in this population.[29]–[31] In fact, depression is an independent risk
factor for multiple readmissions from all causes in the HF population, and more severe
depression has a larger impact on the rate of readmis-sions.[32] Linder et al[33] were among the
first to describe the relationship between depression and readmission. They reported a
significant positive correlation (Spearman r = 0.549, P
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