Research: Three-Step Plan Reduces Patients’ Healthcare Needs After Hospitalization for Heart Failure

A new take on fluid management education by nurses can help keep patients at home and healthier.

Significant volume overload is recognized as a prevalent cause of hospitalization for acute decompensation of chronic heart failure (HF). At Cleveland Clinic, nurses sought to assess the effect of a fluid management education intervention on healthcare consumption. They found that using a theoretical model to discuss the problem of heart failure and how to control it, and incorporating a three step action plan into the intervention, reduced rates of emergency department visits and rehospitalization for HF decompensation over a six-month period compared with standard patient education.

The findings emerged from a comparative study among 244 patients with chronic HF who were enrolled while hospitalized at Cleveland Clinic. Healthcare consumption was measured in both the intervention and usual-care groups over the six months following patients’ discharge from the hospital. “With our standard education, too many patients were returning with fluid issues,” says lead researcher George Rouse, BSN, RN, assistant nurse manager of the cardiac step-down unit at Cleveland Clinic’s main campus.

Applying the Common Sense Model of Illness

The intervention used the Common Sense Model of Illness as a framework for understanding HF. The Common Sense Model recognizes that patients’ illness perceptions influence their coping behaviors (in this case, how patients with heart failure control worsening signs and symptoms), and coping behaviors were hypothesized to influence medical outcomes. Two four-page pamphlets explaining heart failure itself and fluid management guidelines were integral to the intervention.

“The first pamphlet addresses heart failure — its identity (signs and symptoms, and that it can worsen silently), causes, timeline, consequences and how to control it. The second pamphlet explains why each step in the three-step action plan is important and how patients themselves can control their heart failure,” notes Rouse. “The idea is that if patients better understand heart failure and the action steps, patients are more likely to manage their heart failure when they experience weight gain or edema.”

The short pamphlets are not a replacement for the heart failure handbook that patients receive as part of usual care, says Rouse, who developed the pamphlets with Nancy Albert, PhD, CCNS, CHFN, CCRN, NE-BC, Senior Director, Nursing Institute Office of Research and Innovation.

The three-step action plan consists of:

1. Daily weighing and monitoring of weight for changes
2. Limiting total sodium intake and advice on how to achieve this goal when weight increases
3. Limiting fluid intake, advice on how to achieve this goal, and circumstances necessitating use

Each step in the plan is accompanied by text in a shaded box clearly labeled, “Why this is important.”

Time Well Spent

The pamphlets’ key messages were reinforced in one-on-one teaching sessions to accommodate patients’ differing education levels. “We reviewed the pamphlets with the patient and asked them to verbalize the action plan steps,” says Rouse. Although the time spent in the one-on-one sessions was substantial, he says, the total time with each patient was probably no more than that typically spent over several days.

The six-month follow-up showed that the intervention was successful. Since patients receiving the education intervention had a lower rate of unplanned use of healthcare services after hospital discharge, the next step in the research process is to discuss results with interdisciplinary healthcare team leaders and determine steps for translating research into practice.

A manuscript based on the research will be developed for publication in a peer-reviewed nursing journal so the findings can be shared with others. “We hope that other nurses will replicate the research intervention in their centers so that we can determine if the differences between groups (effect) are specific to us or are generalizable,” says Albert, who was a co-investigator on the study.

Keywords: Quality Improvement, Staffing