Running head: DECREASING CHF EXACERBATIONS THROUGH EDUCATION
Decreasing Overall Number of Congestive Heart Failure Exacerbations Through Increased
Availability of Educational Materials
Jeffrey A. Carameros & Vidya Maharaj
University of Central Florida
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DECREASING CHF EXACERBATIONS THROUGH INCREASED EDUCATION
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Abstract
Congestive heart failure is decreased pumping ability of the heart which results in increased
buildup of excess fluid and third spacing. Exacerbations are frequent, and may require repeat
hospitalizations if not managed optimally on in an outpatient care setting. The Cardio-renal
clinic run by Cecelia Bato in Marion County, FL offers heart failure patients an opportunity for a
multidisciplinary approach to their heart failure care. Although education is provided verbally to
patients, currently there are no available posters or banners to use in developing an informed
patient. To improve the educational opportunities for patients of this clinic, we will prepare
posters and banners concerning the mission statement and vision of the clinic, symptoms of the
disease process, barriers to treatment, options for care, and readmission statistics. Determination
of benefit will be obtained through use of a “before” and “after” teaching questionnaire that will
be designed to evaluate improved patient knowledge base. Although the knowledge
requirements may seem daunting, they are attainable through the implementation of written
education in the form of poster-boards and banners. With these, questionnaires will be provided
to evidence the benefit of this type of approach to education. Expectation is that through use of
this type of educational offering, patients will be able to increase knowledge of their disease and
decrease the incidence of exacerbations and hospitalizations.
DECREASING CHF EXACERBATIONS THROUGH INCREASED EDUCATION
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Decreasing Overall Number of Congestive Heart Failure Exacerbations Through Increased
Availability of Educational Materials
Congestive heart failure (CHF) is a decrease in the pumping function of the heart which
eventually delivers an inadequate amount of oxygenated blood to the body. It occurs when the
muscles of the heart are weak and/or atherosclerotic, and the oxygen demands of the body are
greater than the heart can deliver (Neubauer, 2007). Eventually, the heart is unable to handle the
increased fluid and enlarges to compensate the increased amount of fluid. The remaining fluid
that the heart is unable to handle is then third spaced within the lungs, extremities, or liver. When
the lungs become congested, pulmonary edema develops and exercise tolerance decreases.
Congestion exhibited within the extremities is shown in the form of edema which can further
lead to wound development. Congestion within the hepatic system results in an impaired ability
of the body to rid itself of wastes and produce protein.
Literature shows the prevalence of congestive heart failure is rising (Fletcher & Thomas,
2001). It affects approximately 4.8 million people in the United States and is diagnosed at a rate
of up to 700,000 new cases annually. Over two million outpatient clinic visits occur annually as a
result of the disease at an approximate cost of ten billion dollars annually, and there are over five
billion diagnosed cases nationally. Given the staggering number of affected people and the
astonishing costs, it is reasonable to believe that CHF is a major health disparity that may
improve through close monitoring by a nurse practitioner directed heart failure treatment
program (Fletcher & Thomas, 2001). One such program is the Cardio-Renal Clinic operated by
Cecilia Bato ARNP under the umbrella of Ocala Critical Care and Kidney Group. With a patient
base of approximately 300 active patients, approximately 12 patients receive face to face care
DECREASING CHF EXACERBATIONS THROUGH INCREASED EDUCATION
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daily through written and verbal education and medication regimen adjustments. Additionally,
new patients may be seen for up to two hours on their initial visit to determine goals and provide
necessary education. In Marion County, however, there are nearly 20,000 diagnosed cases of
CHF according to Bato (2011). The disparaging factor is that there are currently only two
dedicated heart failure treatment clinics in Marion County. As such, most patients have their
heart failure treatment either managed by primary care practitioners or not managed at all. At the
Cardio-Renal clinic, a multidisciplinary approach to treating patients with the disease is the goal.
As such, in addition to heart failure education, diet and nutritional education are provided along
with diabetic monitoring. In spite of this, however, admission and readmission rates are still high
(Heart Failure Society of America, 2010).
The current mission statement for the clinic is to “provide comprehensive, quality heart
failure care using evidence -based guidelines in (a) collaborative management setting to improve
patient’s quality of life, inculcate patient self-empowerment, prevent exacerbation of symptoms,
and slow down the progression of heart failure” (Bato, 2011). Their vision statement is three
part. Their primary desire is that the program continuously stands out as providing superior heart
failure care that is well organized, economical, and preventative (Bato, 2011). Secondly, they
desire to be able to offer access of this care to all heart failure patients within the county and
neighboring cities. Lastly, they desire to offer a program that is recognized within professional
practice for its clinical excellence in providing heart failure care both locally and nationally.
Based on these desires for clinical excellence in patient care, the clinic has adopted current
treatment guidelines from the Heart Failure Society of America and the American Heart
Association. In both of these agencies, both pharmacologic and non-pharmacologic interventions
are explored. Although pharmacologic considerations for treatment are the primary treatment
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modality, without education surrounding the purpose of that treatment, compliance may not be
optimal. On the other hand, non-pharmacologic interventions are resultant from the education the
patient has received and their retention of it including their perception of its value. As a result of
increased availability to education surrounding heart failure, patients can obtain the knowledge
necessary to prevent or decrease the incidence of hospitalization. As health care providers, we
must determine the methods needed to reach necessary outcomes in CHF management. Since
over five million Americans are currently living and dealing with CHF, we should stress the
importance of CHF education including signs and symptoms, prevention and treatment. Patients
with CHF and their families require teaching of the signs and symptoms of CHF exacerbation.
This is in line with the fact that if signs and symptoms of CHF are not recognized early enough
or not addressed effectively, then serious consequences such as severe respiratory distress or
even cardiac arrest can occur. Heart failure patients need to know these signs of exacerbation so
they may seek help from their doctor, the emergency room, and the heart clinic. In turn, this will
lead to reduced readmission rates at the hospital (Krumholz, et al., 2000). The signs and
symptoms we propose to teach CHF patients through educational posters and banners are as
follows:
1. Extreme shortness of breath when laying down flat or worsening during exertion is not
normal. Having to use pillows for propping themselves up to breathe effectively is a sign
to go see a health care practitioner. Shortness of breath while lying down is a classic and
telltale sign of a weakened heart due to fluid overload (Jessup, 2009).
2. Swelling of the hands and feet and rapid weight gain of more than two pounds in one day
or five pounds is a sign of an impending exacerbation (Jessup, 2009, Hunt, et al., 2005)
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3. Fatigue even with the simplest activity is not to be expected. Exercise intolerance may
also be decreased.
4. Persistent nagging cough or coughing up blood.
5. Increased abdominal girth, abdominal pain, and nausea may also be signs of fluid buildup.
6. Frequent urination during the night may be due to excess fluid in the body.
7. Irregular or rapid heart rate.
8. Sensation of “racing heart” or palpitations.
9. Loss of appetite.
10. Difficulty sleeping.
11. Swelling under the right rib cage at the liver.
According to a study completed by Boyde et al. (2009), heart failure patients typically rely
on poster information followed by brochures and videos. This type of approach to education is
augmented by congruence of teaching with their heart failure providers. As such, posters and/or
banners are this study’s concentration for providing increased access to available teaching.
Boyde et al. (2009) also identified barriers to improved care and quality of life as lack of ability
to speak freely and on the same cognitive level with their providers. Patients desired to be
provided with information regarding diagnosis in layman’s terms. They relied more heavily on
their providers directly for this information than they did on the internet. However, they did
prefer their providers to be able to offer this information in writing as well so they may be able to
both see and hear it, thereby increasing retention.
In order to increase access to readily available education to heart failure patients, we
propose to create wall hangings and banners to be used in the educational area of the clinic. It is
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intended to offer dual education for the patient. They are free to read the information regarding
barriers to compliance, symptoms, current treatments, and admission/readmission statistics. Also,
the RN or ARNP who provides the education and teaching for their patients will be able to
quickly use it as a teaching tool. All of the information which is to be included in the wall
hangings and banners will be drawn from the same organizations which the clinic models their
treatment around: the American Heart Association and the Heart Failure Society of America.
The purpose of this is to improve areas that have previously been identified as barriers to
compliance. As such, a questionnaire will be provided for each new patient with approximately
twenty questions designed to test their knowledge surrounding heart failure both before teaching
is completed and after teaching is completed. The same questionnaire will also be provided to
patients who have undergone previous teaching at the clinic, but to whom these teaching tools
were not available previously. Comparison will be made between both study groups in order to
determine the effectiveness of the posters and banners as teaching tools. Overall, the goal is
essentially to provide the most optimum education for heart failure patients that will eventually
improve quality of life and improve readmission rates.
The questionnaire will contain the following statements and will be marked as either “true”
or “false” by having the patient circle the appropriate choice. No punch cards or fill in the bubble
type answer sheets will be used. Only “true” or “false” answers which are obviously circled will
be acceptable for use in the study. Sheets which are incompletely or incorrectly filled out will be
discarded from the study.
1. CHF is not a serious, life threatening disease.
2. Yearly readmission rates to the hospital range from 21% to 27%.
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3. As patients, there are certain precautions that we can take to prevent readmission to
the hospital.
4. The CHF clinic is a good resource for CHF patients.
5. The mission of the CHF clinic is to provide quality patient care for overall patient
care.
6. The CHF clinic is noted for its overall clinical excellence in heart failure treatment.
7. It is permissible for a heart failure patient to gain more than five pounds in a week.
8. If I have shortness of breath at any time, it is permissible to ignore it.
9. Persistent coughing or wheezing is normal for a CHF patient.
10. Edema is swelling of the hands and feet.
11. I should proceed to the nearest emergency room as soon as possible for increasing
shortness of breath or chest pain.
12. My family members should be aware of signs of a CHF exacerbation.
13. Some of the medications used to treat CHF have side effects.
14. It is okay for a heart failure patient to consume more than two grams of sodium per
day.
15. Exercise is not advised for heart failure patients.
16. It is not necessary for CHF patients to have their blood pressure controlled as it is
expected to fluctuate a great deal.
17. If I have a “bad” heart valve, valve surgery is a good option.
18. It is okay for a heart failure patient to drink alcohol.
19. I should follow up with my doctor on a routine basis and sooner if symptoms of CHF
exacerbation develop.
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20. As a CHF patient, I know that the CHF and cardio-renal clinic is a good resource for
me to use.
As well as teaching patients to identify symptoms of CHF, patients will also be educated on
how to prevent CHF exacerbations through making lifestyle modifications and adjustments.
Prevention measures intended to be taught include:
1.
Smokers need to quit smoking. Not only does the use of tobacco have adverse effects on
the lungs, it can also increase the progression of heart disease.
2.
Exercise done in moderation, such as walking, swimming and light cycling can help
improve cardiac function and muscle.
3.
Diet plays a major role in the treatment and progression of CHF. The two most
detrimental ingredients in the diet of a CHF patient are salt and alcohol. Salt allows the
body to accumulate water which can be a dangerous situation for patients with CHF.
Heart failure patients should avoid salty snacks such as potato chips, pretzels, popcorn,
table salt, soy sauce, canned soups , canned vegetables and cured meats. Patients are
encouraged to consume not more than two grams of sodium a day. Fresh fruits and
vegetables should be the highlight of their diet. It might be an excellent idea to meet
regularly with a dietician to develop a meal plan consistent with a CHF diet.
4.
Alcohol in CHF patients makes the heart more sluggish. This includes all forms of
alcohol such as beer, vodka, wine and whisky. One or two drinks a day may be
permissible for people with normal heart function, but not for heart failure patients.
5.
Although drinking large amounts of water is beneficial for patients without CHF, it is
contraindicated in patients with CHF since treatment for CHF is directed toward ridding
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the body of excess water. The saying that “drinking eight to ten glasses of water a day is
healthy” does not apply to patients with CHF.
6.
Reading labels on food containers is a good habit.
7.
Patients should be educated and knowledgeable about the medicines they take and keep
an up to date list with them at all times. Most importantly, they should take their
medicines as prescribed in order to keep the disease process under control. Certain
medications used in the treatment of heart failure in order to decrease the workload of the
heart include ace-inhibitors, angiotensin receptor blockers, beta-blockers, diuretics,
digoxin, potassium, and oxygen.
8.
Patients with advanced CHF or those that are in the hospital frequently for CHF
exacerbation will be encouraged to enroll and continually participate in an outpatient
CHF clinic such as the Cardio-Renal clinic or the Heart of Florida if in Marion County,
FL. Compliance with this type of outpatient therapy is a major determinant factor in the
prevent of readmission to the hospital. Patients need to be educated to know that there are
community resources available for them to use.
9.
Patients will also be encouraged to weigh themselves on a daily basis and report any
rapid weight gain to the clinic or other health care provider immediately. A weight gain
of two to three pounds over two to three days should be a red flag to take action
(Fonarow, 2008). Diuretics may have to be increased or changed at various points in
treatment, but only under the direction of their healthcare provider.
10.
If overweight, the patients will be encouraged to lose weight (Mikati, 2009).
11.
Patients will be advised to strictly adhere to their doctor’s appointments and not to miss
them for proper evaluation and follow-up care especially since they can have other co-
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morbidities such as coronary heart disease, emphysema, high cholesterol or even
diabetes. Patients will be educated that it is the team effort in the provider/patient
relationship that will work the best. Additionally, certain diagnostic tests such as chest xray, EKG, echocardiograms, lab tests such as CBC, CMP, BNP and urinalysis may need
to be done.
12.
If the heart failure can be attributed to damaged heart valves, patients will be educated
that valvular heart surgery and/or valve replacement may be an option (Hess & Carroll,
2007).
13.
Angioplasty and coronary stenting can be considered for patients whose heart failure is
caused by inadequate blood flow to the heart due to blocked vessels (Hess & Carroll,
2007).
14.
Blood pressure control is an important factor in keeping CHF under control. Patients will
be requested to keep a daily log of their blood pressure, take their medications as
directed, and bring all logs and medication bottles to each appointment (Hunt, et al.,
2005).
15.
Abstinence from alcohol use can significantly improve heart muscle that has been
weakened by previous alcohol abuse (Mikati, 2009).
16.
Having a strong support system when living with CHF is quite a challenge, but there are
people in the community that are available for support and who truly care (Mikati, 2009).
As evidenced above, heart failure patients require enormous amounts of education
regarding their disease process. This education must provide the definition of the disease,
symptoms of the disease, symptoms of disease exacerbation, preventative measures, and
expectations for lifelong treatment. Although the knowledge requirements may seem daunting,
DECREASING CHF EXACERBATIONS THROUGH INCREASED EDUCATION
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they are attainable through the implementation of written education in the form of poster-boards
and banners. With these, questionnaires will be provided to evidence the benefit of this type of
approach to education. Benefit analysis will be completed following the standard true/false
answers on the questionnaire. Expectation is that retention of education through this use of
information will increase patients’ overall knowledge base and thereby improve patient
outcomes.
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References
Angeli, E., Wagner, J., Lawrick, E., Moore, K., Anderson, M., Soderland, L., & Brizee, A.
(2010, May 5). General format. Retrieved from
http://owl.english.purdue.edu/owl/resource/560/01/.
Bato, C. (2011). Personal interview on 3/23/2011.
Boyde, M., Tuckett, A., Peters, R., Thompson, D., Turner, C., & Stewart, S. (2009). Learning for
heart failure patients (The L-HF patient study). Journal of Clinical Nursing. 18: 20302039.
Fletcher, L. & Thomas, D. (2001). Clinical Practice. Congestive Heart Failure: understanding the
pathophysiology and management. Journal of the American Academy of Nurse
Practitioners. 13(6): 249-257.
Fonarow, G., et al (2008). “Factors Identified as Precipitating Hospital Admissions for Heart
Failure and Clinical Outcomes: OPTIMIZE-HF”. Arch. Internal Medicine:168(8): 847854.
Heart Failure Society of America. (2010). 2010 Comprehensive Heart Failure Practice Guideline.
Retrieved from http://www.heartfailureguideline.org/.
Hess, O. & Carroll, J. (2007). Management of heart failure patients with reduced ejection
fraction. Libby: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine,
8th ed.
Hunt, S. et al. (2005). ACC/AHA 2005 Guideline Update for the Diagnosis and Management of
Chronic Heart Failure in the Adult. Journal of American Cardiology; 46: 1-82.
Jessup, M., et al (2009). Focused update: ACCF/AHA Guidelines for the diagnosis and
Management of Heart Failure in Adults: a report of the American College of Cardiology
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Foundation/American Heart Association Task Force on Practice Guidelines: developed
in collaboration with the International Society for Heart and Lung Transplantation. 119
(14): 1977-2016.
Krumholz, H., et al (2000). “ Predictors of readmission among elderly survivors of admission
with heart failure”. American Heart Journal. 139: 72-7.
Mikati, I. (2009). Evaluating patients with CHF symptom diagnosis and management. Retrieved
on April 26th from http://www.medicinenet.com/congestive_heart_failure/discussion24.htm.
Neubauer, S. (2007). “The failing heart- an engine out of fuel”. New England Journal Medicine.
356 (11): 1140-51.
DECREASING CHF EXACERBATIONS THROUGH INCREASED EDUCATION
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University of Central Florida
College of Nursing
Nurse Practitioner Programs
Community Based Project
Students:
Jeffrey A Carameros
JCarameros@msn.com
352-484-7460
Vidya Maharaj
Maharaj@knights.ucf.edu
352-209-1798
Project Name: Ocala Community Project
Location:
2980 SE 3rd Court
Ocala, FL 34471
Faculty Contact: Dr. Diane Wink
Community Agency Contact: Cecelia Bato ARNP
Community Agency Contact email:
Community Agency Contact phone number/fax: 352-622-4231, 352-622-0518
Community Agency Contact address: 2980 SE 3rd Court, Ocala, FL 34471
Goals:
1. Increase patient participation in daily monitoring of CHF signs and symptoms.
2. Patient will be able to identify exercises that will decrease the likelihood of CHF
exacerbations by improving or maintaining heart function.
3. Patient will be able to recognize alarm symptoms of a CHF exacerbation as well as know
when to seek help.
4. Patient will be able to state proper dietary intake and what foods/fluids to avoid.
5. Patient will be able to identify side effects of prescribed heart failure medications.
6. Hospitalizations related to CHF exacerbations will decrease as a result of improved education
and increased compliance.
Student responsibilities:
1. Identify ways in which CHF education may be further provided to affected clients.
2. Obtain goal and mission statements for clinic and present in an educational manner to
patients.
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3. Prepare educational material in the form of banners/poster boards to be presented as a
learning tool for the CHF clinic by identifying symptoms and treatment options.
4. Assess current knowledge level of CHF patients through a short 10 question quiz, and
compare it to the same repeated quiz after the above educational tools are used.
5. Review current guidelines set for the by Heart Failure Society of America, the American
College of Cardiology, and the American Heart Association, and use these guidelines to
prepare education for CHF patients.
6. Provide admission/readmission statistics for patient review.
Collaborating partners responsibilities:
1. Provide students with clinics goal and mission statements for evaluation and assistance in
preparing it for presentation to patients.
2. Present 20 question quiz to established patients and repeat quiz following education with
newly prepared poster boards.
3. Guide patients in the educational direction and style desired for the prepared educational
materials.
4. Review and critique prepared educational materials to be in line with clinic expectations.
Projected timeline over the two semesters: 6 months
Acceptance:
_electronically signed_____
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Cecelia Bato
Jeffrey A Carameros
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Vidya Maharaj