Running head: THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

The Effects of Patient Education and CHF Readmission

Nicole Bramwell
University of South Florida

Abstract

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

Congestive heart failure is characterized as a type of cardiac dysfunction that affects the
pumping ability of the heart. The disease can cause debilitating symptoms of weight gain,
fatigue, edema, shortness of breath and among other symptoms. Without the tools to properly
self- manage, the disease process can lead to frequent hospitalizations and decreased the quality
of life. The purpose is to explore the role of increased patient and follow up teaching in
decreasing readmission rates for heart failure patients. The articles referenced were found using
the search engines PubMed and CINAHL. The keywords specifically used in PubMed and
CINAHL were CHF readmission and CHF and patient teaching. The study performed by
Delaney et al. (2013) showed that after 90 days with post-home care discharge hospitalization
was significantly reduced in the experimental group (p =. 046), heart failure knowledge and
quality of life also improved (p =.013, p =.004) in the experimental group as compared to the
control group. The second study performed by Sales et al. (2013) demonstrated that patients that
received the intervention had a decreased 30-day readmission as compared to the controlled
group (7% vs 19%, p < .05). The last study referenced was performed by Kommuri, Johnson,
Koelling (2012) The results showed that the experimental group had significantly higher heart
failure knowledge scores compared to the patients receiving the standard care (p = 0.007). The
three articles discussed above will be further examined to support and answer the question in
patients hospitalized with a diagnosis of CHF (P) how does face to face patient teaching and
follow up teachings after discharge (I) compared with patients that do not receive follow-up
teaching (C) affect the rate of readmission (O) within thirty days (T)?

The Effects of Patient Education and CHF Readmission

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

Congestive heart failure (CHF) is one of the major causes of death and disability in the
United States (Delaney et al., 2013). Heart failure affects over six million Americans, causing a
major public health problem among the population. In the United States, there are over 550,000
new cases of heart failure diagnosed each year (Osborn et al., 2014). Congestive heart failure is
the leading cause of hospitalizations among adults older than 65 years old. Over fifty percent of
patients that are admitted to the hospital are diagnosed with congestive heart failure, accounting
for over 17 billion dollars Medicare spends annually for those hospitalizations (Sales et al.,
2013). However, when many of those patients are discharged they are soon re-admitted. Patients
admitted to the hospital with a diagnosis of heart failure 13% are readmitted to the hospital in
fifteen days and in thirty days approximately 25% of the patients are readmitted (Sales et al.,
2013). Readmission to the hospital is common in patients with congestive heart failure due to
improper self-care. Without proper management of CHF, the disease will progress and lead to a
decreased quality of life, worsening symptoms, and frequent hospitalizations (Sales et al., 2013).
The aim of the review of literature is to find evidence to support and answer the question in
patients hospitalized with a diagnosis of CHF (P) how does face to face patient teaching and
follow up teachings after discharge (I) compared with patients that do not receive follow-up
teaching (C) affect the rate of readmission (O) within thirty days (T)?
Literature Search
The literature that will be discussed was found through two search engines, PubMed and
CINAHL. To find the three articles in both search engines, the search was refined by choosing
peer-reviewed articles, include articles within the last five years, and randomized control trials.
In the PubMed search engine the keywords used were patient education and CHF and CHF and
readmission. The search in PubMed with the keywords CHF and readmission provided the one

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

source of literature that will be discussed. In the CINAHL search engine patient teaching and
CHF and CHF and readmission. Each keyword search produced one article which will also be
discussed in detail.
Literature Review
Delaney et al. (2013) performed a randomized controlled was performed to test the
effects of either telemonitoring and patient education on readmission rates for patients diagnosed
with CHF. The outcomes measured were hospital readmission rate, improved quality of life, and
increased CHF knowledge. The study included 100 participants 50 patients were randomly
assigned to both the experimental and control group. The study showed that after 90 days with
post-home care discharge hospitalization was significantly reduced in the experimental group (p
=. 046), heart failure knowledge and quality of life also improved (p =. 013, p =. 004) in the
experimental group as compared to the control group. The sample size of the study was small,
the participants were predominantly white, limited to one geographic area, and one agency.
These limitations reduced the findings to be generalized to diverse ethnic populations. The
strengths of the study are the participants were randomly assigned, reasons why the subjects did
not complete the study, the subjects in each of the groups similar on demographic and baseline
variables.
Sales et al. (2013) utilized trained volunteers to provide dietary and medication
education, follow-up phone calls within 48 hours after discharge, and a month of weekly phones
as compared to the control group which received the standard care in reducing 30-day
readmissions in heart failure patients. Sales et al. (2103) performed a randomized control to test
the efficacy of patient teaching in CHF patients. The study had a sample size of 137 participants

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

n= 70 patients in the experimental group and n= 67 patients were in the control group. The
results demonstrated that patients that received the intervention had a decreased 30-day
readmission as compared to the controlled group (7% vs 19%, p < .05). The strengths of the
study are the patients were randomly assigned, the sample size was diverse in terms of race and
socioeconomic factors, and measuring outcomes were valid and reliable. The main weakness of
the study sample size is small, the exclusion criteria were not included, the study was not doubleblinded.
A randomized controlled trial was performed by Kommuri, Johnson, & Koelling (2012)
to test the effectiveness in performing one hour, one-on-one teaching session with the a nurse
educator to increase disease-specific knowledge as compared to the standard discharge process in
patients with heart failure. The study measured heart failure knowledge in patients before, after,
and three months later. The study included 265 participants 137 patients were randomly assigned
to the control group and 128 were randomly assigned to the experimental group. The results
showed that the experimental group had significantly higher heart failure knowledge scores
compared to the patients receiving the standard care (p = 0.007). Patients that were either
readmitted to the hospital or died after three months had significantly lower heart failure
knowledge scores (p = 0.002). The weakness of the study were it did not assess the relationship
between self-care knowledge and clinical outcomes, the criteria for inclusion of the study was
not included, and the sample size was moderate. The strengths of the study are participants were
randomly assigned, assess increased heart failure knowledge is valid, and the reason why
participants were excluded was provided.
The clinical practice guidelines for CHF include a comprehensive discharge planning that
should include links with post-discharge services are in place for all those with symptomatic

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

heart failure patients (Management of chronic heart failure, 2012). Next, a follow up (including
by telephone) by trained heart failure nurses should be considered for patients post-discharge or
with stable heart failure (Management of chronic heart failure, 2012). Last, patients with heart
failure should be offered multidisciplinary follow up, including pharmacy input to address
knowledge of drugs and compliance (Management of chronic heart failure, 2012). The literature
tested two of the clinical practice guidelines and proved the effectiveness of those clinical
guidelines in heart failure patients. Thus supporting that face to face teaching and follow-up post
discharge teaching can help decrease 30-day readmission rates in heart failure patients.
Synthesis
Delaney et al. (2013) demonstrated that after 90 days with post-home care that included
reinforced teaching after discharge significantly reduced re-hospitalizations in the experimental
group (p =. 046). Also, Sales et al. (2013) research proved patients that received dietary and
medication education, follow-up phone calls within 48 hours after discharge, and a month of
weekly phone calls had significantly decreased 30-day readmission as compared to patients that
did not receive the intervention ( p=<.05). Last, Kommuri, Johnson, & Koelling (2012) revealed
that one-on-one, one-hour teaching to patients at discharge significantly increased patient
knowledge about heart failure (p = 0.007).
The literature demonstrates that face to face teaching and follow-up teaching after
discharge significantly reduce the rate of re-admission in heart failure patients. The similarity
within each study shows health care professionals going beyond handing out pamphlets at
discharge, but taking the time at discharge and after discharge to make sure patients understand
their disease and how to manage it effectively. These studies impact patient care by showing the

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

importance of the patient education in disease management. The gaps within the field of heart
failure management are instituting this research into practice. There is a gap to bridge between
implementing this standard of patient teaching within the hospital setting.
Clinical Recommendations
The evidence shows that hour face to face and follow-up teaching in patients with CHF
can significantly reduce readmission rates within the population. Utilizing face to face and
follow up teachings in patients that suffer other chronic diseases to prevent hospital readmission.
In hospitals, discharge teachings should be face to face and longer than the standard of fifteen
minutes and follow up phone calls made to the patients. In order for clinical practice to become
evidence-based nursing staff or educators may take over discharge process and initiate follow-up
calls. Ultimately, more research will need to be done to search for the adequate time and length
of teaching is effective in a larger sample size to confirm validity. Taking an active role in
patients health after discharge can prove to increase the quality of life and decrease hospital
readmissions.

References

THE EFFECTS OF PATIENT EDUCATION AND CHF READMISSION

Delaney, C., Apostolidis, B., Bartos, S., Morrison, H., Smith, L., & Fortinsky, R. (2013). A
randomized trial of telemonitoring and self-care education in heart failure patients
following home care discharge. Home Health Care Management & Practice, 6(5), 187195. doi:10.1177/1084822312475137
Kommuri, N., Johnson, M., & Koelling, T. (2012). Relationship between improvements in heart
failure patient disease specific knowledge and clinical events as part of a randomized
controlled trial. Patient Education and Counseling, 86(2), 233-238.
doi:10.1016/j.pec.2011.05.019

Management of chronic heart failure (October 25,2012). National Guideline Clearinghouse.

Retrieved October 27, 2015, from http://www.guideline.gov/content.aspx?id=10587

Osborn, K., war, C., Watson, A., & Holleran. (2014). Caring for the patient with coronary artery disease.
in medical-surgical nursing: preparation for practice (2nd ed., p. 925-927). Boston: Pearson.

Sales, V. L., Ashraf, M. S., Lella, L. K., Huang, J., Bhumireddy, G., Lefkowitz, L., Heitner, J. F.
(2013). Utilization of trained volunteers decreases 30-day readmissions for heart failure.
Journal of Cardiac Failure, 19(12), 842-850. doi:10.1016/j.cardfail.2013.10.008