Step-by-step teaching shaves CHF readmission
Step-by-step teaching shaves CHF readmission
Vary teaching, reinforce lessons via the telephone
A systematic approach to education has impacted readmission rates for patients with congestive heart failure (CHF) at Northwest Medical Center in Thief River Falls, MN. This rural, 90-bed hospital saw rates for Medicare patients drop from a 30% readmission rate to 0% when they implemented a step-by-step education plan in 1994.
The steps include a good learning assessment, an educational plan that uses a variety of teaching methods, and follow-up to help reinforce the teaching since many of the patients live 70 or more miles from the hospital and cannot return for outpatient classes.
A key element of the education process is helping patients become familiar with the signs and symptoms that should prompt them to call their doctors, says Evadell Tangquist, RN, patient education coordinator at Northwest Medical Center. These include having a weight gain of two to four pounds in a week, which indicates retention of fluids; having dizzy spells or feeling faint; becoming tired faster than usual; or developing a tightness or pain in the chest.
Patients are taught the signs and symptoms of CHF problems while they are in the hospital, and Tangquist makes sure each patient can repeat them when she makes her follow-up calls. Yet, identification of symptoms that warrant prompt medical attention is just one element that has helped keep readmissions down. Following is the step-by-step approach used to educate CHF patients at Northwest Medical Center:
• Conduct a learning assessment.
A form to determine if a patient is ready to learn and what barriers to education exist was created to assess the learning needs of all inpatients shortly after the Joint Commission on Accreditation of Healthcare Organizations implemented its patient education standards. It helped ensure that education would be adapted to the patient’s situation, says Tangquist. For example, if a patient is too sick to learn, a family member is taught the need-to-know information before discharge. (See copy of assessment in CHF educational supplement in this issue.)
• Use varied teaching methods.
The education process begins with a video produced by Timonium, MD-based Milner-Fenwick titled "Congestive Heart Failure." It continues with one-on-one education.
Tangquist, who does the teaching for all CHF patients, uses the patient’s treatment plan as a guideline. She covers taking medications as directed, reducing sodium in daily diet plans, eliminating the use of harmful substances such as tobacco and alcohol, monitoring activities and exercise, and recognizing signs and symptoms for CHF that require medical attention. A dietitian also goes over the patient’s diet regimen.
According to Tangquist, a patient is most often noncompliant in three areas:
Medications: They quit taking their medicine when they feel better or don’t fill the prescription because they can’t afford it.
Diet: They don’t read labels and, therefore, eat food that is high in sodium.
Activities: When they feel good, they do too much. As a result, they feel bad the next day.
Booklet used as home reference
To help reinforce teaching, patients are given a booklet on CHF that includes much of the information Tangquist covers. As she educates the patients, she shows them where to look in the booklet to find the information she covers in the one-on-one teaching so they can use it as a reference at home.
• Reinforce teaching with follow-up.
Because the hospital is located in a rural community, it is difficult for patients to return to the hospital for additional education. Yet patients are often very sick when they are in the hospital, and it is difficult for them to learn. That’s why telephone follow-up was initiated, says Tangquist. It’s an opportunity for her to reinforce what the patients learned and teach them what they do not know.
The first phone call is initiated 48 to 72 hours after discharge and is routine for all patients at Northwest Medical Center. It’s a short call to see how the patient is doing and if he or she has any questions.
Tangquist makes a second call two weeks after discharge. At this time, she reviews the patient’s treatment plan. Tangquist makes sure medications are being taken correctly, the diet plan is being followed, and the patient is exercising according to physician instructions. She also makes sure the patient knows when he or she should see the doctor to prevent an acute episode. If the patient doesn’t know the signs and symptoms, Tangquist asks that he or she get the booklet on CHF that was distributed in the hospital and reviews the pages over the telephone.
When patients don’t seem to be compliant, Tangquist makes a note in their record and calls them back a couple of weeks later to go over the information again.
• Include family members in education.
A family member is always included in the education. Whenever possible, it is the person who lives with the patient, such as a spouse. Also, a family member who will be visiting the patient frequently and watching them closely, such as a son or daughter, works well.
"It’s good to include others in the education because the patient may be hearing only what they want to hear," says Tangquist.
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