Hospital Discharge Education For CHF

Clinical Article
Hospital Discharge Education

for Patients With Heart Failure:
What Really Works and
What Is the Evidence?
Sara Paul, RN, MSN, FNP
PRIME POINTS
Educating patients
before discharge
promotes self-care,
reduces readmissions,
and helps patients spot
problems early.
Patients should be
active partners in the

management of their
health.
Patients should
learn about their
conditions and medications and when to
seek medical treatment.
Nurses need to
understand the barriers to self-care and

help patients overcome
these barriers.
espite advances in
therapy, morbidity
and mortality remain
high in patients hospitalized for heart
failure. Although new approaches
to improving the use of guidelinerecommended evidence-based
therapies at hospital discharge are
undeniably needed,1 truly comprehensive and competent care for
patients hospitalized with heart failure requires a strong focus on education of patients and their families.
Education at discharge is a vital
component of improving outcomes
in heart failure. The institution of a
structured system of patient and
family education that involves a
multidisciplinary team and emphasizes medication adherence, sodium
and fluid restrictions, and recognition of signs and symptoms that
indicate progression of disease may
be as important as ensuring that
patients are prescribed appropriate
medical therapy. Specific topics of
instruction for patients hospitalized
with heart failure are listed in Table 1.
Poor adherence to these instructions
can lead to worsening of disease and
rehospitalization. According to esti-
mates, 54% of readmissions may be

preventable, and inadequate discharge planning and education or
lack of patient follow-up are common
factors in readmission.3-5 Lack of
compliance with medications, failure to follow a salt-restricted diet,
and delays in seeking medical attention are among the primary reasons
for the high rate of rehospitalization
among patients with heart failure.6
Patients who are not knowledgeable about their disease and their
medication are at a severe disadvantage. In one study,7 the association
of medication adherence and knowledge was tested in 61 patients age
50 years or older who had heart
failure. Patients knowledge of the
dosage, frequency, and indication
of each of their heart failure medications and patients ability to open
medication bottles, read labels, and
distinguish tablet/capsule colors
were assessed. Lower medication
adherence (P = .001) and an inability to read labels (P = .002) were
significantly associated with an
increased number of cardiovascularrelated visits to the emergency
department. Patients with greater
medication adherence had a mean
66 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

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Table 1
Lifestyle changes required in the self-management of heart failurea
Adopt a low-sodium diet (<3000 mg for NYHA functional class I and II; <2000 mg for
NYHA functional class III and IV)
Restrict fluid intake to 2 L (approximately 8 cups) per day if indicated
Stop smoking
Increase activity/exercise at a low to moderate intensity
Monitor weight daily
Notify health care provider of signs and symptoms of worsening heart failure, such as
weight gain of more than 3 lb (1.3 kg) in a week or 2 lb (0.9 kg) overnight
Eliminate alcohol consumption
Reduce fat and cholesterol in diet if coronary artery disease is present
Learn all signs and symptoms to report to health care provider: pain in jaw, neck, or
chest; increased shortness of breath or fatigue; dizziness or syncope; swelling in feet,
ankles, legs, or abdomen; palpitations; and racing heart (>120 beats per minute)
Abbreviation: NYHA, New York Heart Association.
a Based on data from Albert and Paul.2
(standard deviation) of 0.22 (0.73)

visits to the emergency department
per patient compared with patients
who were less adherent, who had
1.00 (2.47) visits per patient. Overall, greater knowledge of, skills with,
and adherence to medication were
associated with fewer visits.
Education of patients at discharge
promotes self-care, reduces readmissions, and helps patients identify
problems early, increasing the chances
for intervention and improved outcomes. In this article, I discuss the
importance of educating patients
and their families in preventing
rehospitalization for heart failure. I
also address the use of performance
measures to improve patients outcomes and methods for promoting
retention of discharge instructions.
Performance Measures
Related to Discharge
Education for Patients
With Heart Failure
Performance measures are criteria used by organizations to determine whether an organization is
fulfilling its vision and meeting its
patient-focused goals. These measures are standardized to evaluate
hospitals and health care systems,
regardless of location, in order to
promote positive outcomes in patient
care. Performance measures may
reflect medical management of
patients, but they may also assess
aspects of patient care, such as education of patients and their families
at discharge. The latest guidelines
for management of heart failure from
the Heart Failure Society of America
Author
Sara Paul is a nurse practitioner at Western Piedmont Heart Centers in Hickory, North
Carolina. She manages patients with heart failure and runs the heart failure program/
clinic.
Corresponding author: Sara Paul, RN, MSN, FNP, Heart Function Clinic, Western Piedmont Heart Centers, 1771
Tate Blvd SE, Ste 201, Hickory, NC (e-mail: smcpaul@earthlink.net).
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recognize the importance of education and recommend that patients

receive educational materials as part
of the patients complete discharge
instructions.8 These materials should
address recommended activity level,
diet, discharge medications, followup appointment, weight monitoring,
and what to do if signs or symptoms
worsen.2,8,9
The American College of Cardiology/American Heart Association
(ACC/AHA) Clinical Performance
Measures for Adults With Chronic
Heart Failure9 include the following
inpatient performance measures
for patients with heart failure: discharge instructions, evaluation of
left ventricular systolic function,
angiotensin-converting enzyme
inhibitor or angiotensin-receptor
blocker for left ventricular systolic
dysfunction, adult smoking cessation
advice/counseling, and anticoagulant at discharge for patients with
atrial fibrillation. The guidelines
recommend that the clinical care
team collect data and review compliance with these measures on a
routine basis, look for changes, and
adjust practice patterns as necessary to improve performance. The
performance measure of discharge
instructions and its components are
shown in Figure 1.9
The Joint Commission evaluates
4 performance measures for patients
with heart failure that are similar to
those of the ACC/AHA: discharge
instructions (HF-1), assessment of
left ventricular function (HF-2), use
of angiotensin-converting enzyme
inhibitors in patients with left ventricular systolic dysfunction (HF-3),
and smoking cessation counseling
(HF-4). These Joint Commission
core measures require that patients
CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 67

4. Discharge Instructions
Heart failure patients discharged home with written instructions or educational material given to the patient or care giver at discharge
or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment,
weight monitoring, and what to do if symptoms worsen
Numerator
Heart failure patients with documentation that they or their caregivers were given written discharge
instructions or other educational material addressing all of the following:
1. Activity level
2. Diet
3. Discharge medications
4. Follow-up appointment
5. Weight monitoring
6. What to do if symptoms worsen
Denominator
Heart failure patients discharged home.

Included populations:
Discharges with an ICD-9-CM Principal Diagnosis Code for heart failure as defined in table 3
A discharge to home or home care
Excluded populations:
Patients less than 18 years of age
Period of assessment
Hospital discharge
Sources of data
Administrative data and medical records

Rationale
Education of heart failure patients and their families is critical. Failure of these patients to comply with physicians and other health care
providers instruction is sometimes a cause of HF exacerbation. A significant cause of patients failure to comply is lack of understanding. It is, therefore, incumbent on health care professionals to be certain that patients and their families have an understanding of the
causes of heart failure, prognosis, therapy, dietary restrictions, activity, importance of compliance, and the signs and symptoms of
recurrent heart failure. Throrough discharge planning is associated with improved patient outcomes (11).
Reference Recommendation(s)
CMS/JCAHO Core Measure: Heart Failure, HF-1: Discharge Instructions (9).
Method of Reporting
Aggregate rate (standard error) generated from count data reported as a proportion.
Figure 1 American College of Cardiology/American Heart Association performance measure: discharge instructions.
Abbreviations: CMS, Centers for Medicare and Medicaid Services; HF, heart failure; ICD-9-CM, International Classification of Disease, Ninth Revision, Clinical Modification; JCAHO, Joint Commission.
Reprinted with permission from ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures)
Endorsed by the Heart Failure Society of America.
2005, American Heart Association, Inc.
with heart failure receive written

instructions or educational material
at discharge that will adequately
address all of the components
mentioned in the guidelines.10 The
intention is that through use of
these performance measures, the
quality of cardiovascular care will
be improved.11 However, conformity
with these indicators among health
care providers is not guaranteed.
In 1997, medical records from
9 hospitals were retrospectively
reviewed to determine the percentage

of patients who receive the quality of
care indicators derived from the clinical practice guidelines of the Agency
for Health Care Policy and Research.
A total of 1623 hospitalizations for
heart failure were reviewed; the mean
frequencies of documentation of
counseling about medications,
weight, diet, exercise, and smoking
cessation were as follows:
Medications: 97% (range, 95%-98%)
Weight: 6% (range, 3%-12%)
Diet: 70% (range, 58%-94%)

Exercise: 61% (range, 26%-81%)
Smoking cessation: 14% (range,
0%-33%)
The variability of counseling
between hospitals was high, and
documentation may not reflect what
was actually practiced.12 The documentation may or may not have
reflected the extent of the counseling. How the information was conveyed and the depth of the patients
understanding of the information

were not documented. More recently,

data from 81 142 admissions of
patients with heart failure in the
Acute Decompensated Heart Failure
National Registry (ADHERE) were
analyzed to determine rates of conformity with the 4 core performance
measures from the Joint Commission.13 The median rate of conformity with discharge instructions (HF-1)
was only 24% (range, 0%-99%), and
the median rate of conformity with
HF-4 (counseling for smoking cessation) was 43.2% (range, 0%-100%).
A substantial gap in overall performance is apparent among hospitals.
The establishment of educational
initiatives and quality improvement
systems to reduce this variability
may substantially improve care.
Does Compliance With

Performance Measures
Improve Clinical Outcomes?
The relationship between current
ACC/AHA performance measures
for patients hospitalized with heart
failure and clinical outcomes was
investigated in the Organized Program to Initiate Lifesaving Treatment
in Hospitalized Patients With Heart
Failure (OPTIMIZE-HF), a registry
and performance improvement
program for patients hospitalized
with heart failure. Only use of an
angiotensin-converting enzyme
inhibitor or an angiotensin-receptor blocker at discharge was associated with a reduction in mortality
or rehospitalization at 60 to 90 days
after discharge.14 Trials comparing
conventional management of heart
failure with management programs
that included counseling of patients
about diet, exercise, medications,
and monitoring have shown that
disease management programs can
reduce hospital stays and improve

functional status.15 However, these
programs often involve outpatient
programs, such as clinics or home
visits, that are beyond those normally assessed in the ACC/AHA
performance measure on discharge
instructions. It is unclear whether
the discharge instruction performance measure as recorded in the
hospital reflects whether the patients
did or did not receive each defined
component of education. Patient
education may be documented in
the medical record even if the education was cursory and allowed little
time for the patient to absorb and
retain the information.15 Conversely,
many patients and their families are
not ready to learn at the time of
diagnosis, regardless of how thorough
the instructional session may be.
Extensive education may be better
absorbed when a patient is in a stable condition and has adapted to
living with heart failure.16
In the analysis of data from
OPTIMIZE-HF, the discharge instruction performance measure did not
have an effect on mortality or rehospitalization at 60- to 90-day followup.14 Fonarow et al14 concluded that
current performance measures
related to heart failure, other than
the prescription of an angiotensinconverting enzyme inhibitor or an
angiotensin-receptor blocker at discharge, have little effect on patients
outcomes shortly after discharge.
Another OPTIMIZE-HF analysis17
specifically addressed education of
patients; researchers assessed the
characteristics of patients who did
and did not receive the full set of
components from the Joint Commission process-of-care performance
measure (HF-1) and then analyzed
whether receipt of this measure was

predictive of other elements of discharge planning. Credit for the core
measure (HF-1) was not given unless
all 6 components (activity level, diet,
discharge medications, follow-up
appointment, weight monitoring,
and what to do if signs or symptoms
worsen) were documented. Despite
recommendations that complete
instructions be given to patients with
heart failure before hospital discharge,
both the process intervention tools to
facilitate HF-1 and HF-1 itself were
underused. Delivery of the full set of
HF-1 components was significantly
more likely in the 46% of patients who
received process improvement tools.17
Additional measures and/or better
methods for identifying and validating performance measures related to
heart failure may be needed to
improve care and outcomes of
patients with heart failure.14
Data suggest that in practice,
discharge education is not emphasized as an essential component of
optimal care for patients with heart
failure. A retrospective review18 of
medical records at a large, inner-city
teaching hospital of 104 patients
with heart failure showed that discharge counseling about medication
adherence, restricted sodium intake,
and the importance of weight monitoring was provided to only 50%,
48%, and 9% of patients, respectively.
The large number of patients who
are discharged without receiving
education may represent important
missed opportunities to decrease
morbidity and mortality.
Educational Tools and a

Multidisciplinary Team
Critical pathways and in-hospital
instructional tools may improve the

provision and quality of discharge

education. The AHA Get With the
Guidelines heart failure program is
a hospital-based quality improvement program implemented in 2001
to promote the use of up-to-date
guidelines for treating patients with
heart disease and stroke. Currently,
more than 1300 hospitals are enrolled
in the program.19 A key component
is the Patient Management Tool, a
Web-based interactive assessment
and reporting system that tracks
treatment and facilitates evidencebased medicine. This tool helps
caregivers manage patients care by
providing (1) drop-down reminders
of current guidelines at key data
points, (2) prescriptive medication
reminders specific to the patients
disease, (3) printed disease-specific
patient education materials before
discharge, and (4) automated patient
dismissal notes and referring
physician letters.20 An example of
the discharge instructions is shown
in Figure 2.19 This tool includes
education as part of the overall
discharge checklist.
Although many hospitals are
adapting the tools from the Get With
the Guidelines heart failure program
into care, the presence of tools alone
is not enough to guarantee evidencebased practices. In a study21 of how
core measures from the Joint Commission are applied at a university
hospital, availability of standardized
order forms, computer discharge
instructions, and education materials did not lead to improvement in
scores for core measures. The scores
improved only after the appointment
of a dedicated heart failure physician
and nurse practitioner who used
the standardized forms, computer
discharge instructions, and the
education materials. Use of the dedicated heart failure team led to quick
and sustained improvements.21
In addition to verbal information,
a combination of educational materials may enhance a patients ability
to absorb information. Books,
newsletters, videos, CDs, Web pages,
and computer-based programs augment the learning process and offer
further opportunities for education
at patients convenience after discharge from the hospital. Many
patients will need repeated education
through follow-up telephone calls,
newsletters, educational bulletins,
or support groups because of the
volume of information that is given
at the time of hospital discharge.
Educational tools must be a component of multidisciplinary care
provided to heart failure patients.22
The team approach to education of
patients improves patients outcomes.
In one study,23 an intervention group
(n=44) of patients received education from a cardiac nurse educator,
a registered dietitian, and a physical
therapist, along with corresponding
written materials. These patients
received an initial visit, as well as a
follow-up visit from the nurse educator, dietitian, and physical therapist
during the patients hospitalization.
Discharge planning was coordinated
with home health nurses, who reinforced the instructions given in the
hospital. Patients in the control group
who received usual care did not
have access to the nurse educator,
did not automatically receive dietary
and physical therapy consultations,
did not have routine telephone contact after discharge, and did not
receive home visits from nurses
trained in management of heart
failure. Hospital readmission rates
were 4 times higher in the group

of patients who received usual care
(n=77) than in patients in the intervention group. Additionally, patients
in the control group required nearly
50% more skilled nursing care visits
and more than twice as many home
health aid visits than did the patients
in the intervention group. The 6-week
cost savings for the intervention
group was $67 804.
Barriers to Learning
Successful management of heart
failure often requires major lifestyle
adjustments, such as modifications
in diet and activities, compliance
with a complex medication regimen,
and the need to assess and monitor
signs and symptoms. Despite best
efforts at education, helping patients
understand all of the complexities
of their disease and therapy may be
difficult. Many patients have low
levels of knowledge of their disease
and lack a clear understanding of
heart failure and self-care. In a study24
of knowledge level in patients with
heart failure, although two-thirds
of the patients reported receiving
information or advice about self-care
from health care providers, 37% of
patients knew a little or nothing,
49% knew some, and only 14%
knew a lot about heart failure.
Approximately 40% of the patients
did not recognize the importance of
weighing themselves daily, and 25%
did not appreciate the risk of consuming alcohol. Although 80% of the
patients knew they should limit the
amount of salt in their diet, only onethird regularly avoided salty foods.
Understanding patients barriers
to learning may enable nurses to
tailor educational approaches accordingly. Simply communicating a

CARDIOVASCULAR DISEASE DISCHARGE INSTRUCTIONS

Discharge Medications
Dosage
Frequency
Start Date/Time
- Nitroglycerin
- Aspirin
81 mg
- ACE-I/ARB
- Beta-Blocker
- Statin
- Clopidogrel
- Spironolactone
- Pain
Exercise/Activity/Diet/Prescription Information Given: See back for health education and resources
If you smoke, STOP! (Smoking will make heart disease worse and may cause death.)
Booklet Given, see back
Does not smoke - or - Has not smoked in more than 12 months
AMI/CHF Discharge Packet Given
Home Exercise Program Instruction Provided
Drug info/food/drug interaction info provided
Cardiac Rehab Information Provided
Daily Weights Instructions Given-See back
Cardiac Rehab Ordered
Diet __ Low Sodium, Low Cholesterol, high fiber
Your Total Cholesterol: ___
Resources on back reviewed
Driving Instructions Given
May Return to Work on (date) ___________________
Yes
No
Activity: Light activity until follow-up appointment
Follow-Up appointment:
___________
Dr.: ___________________________ Phone: ___________________________________ Date: ___________
___________
Dr.: ___________________________ Phone: ___________________________________ Date: ___________
Home Care Agency: _______________________________ Phone: ___________________________________ Date: ___________

MD/RN Signature _________________________________________________________________________ Date ______________
Choices Provided on ______________________________ :CM Signature ________________________________ Date __________
I have received a copy of this form and understand the instructions. Patient signature ______________________________________
NOTE: Any old, unused pills or liquid at home should be flushed down the toilet. Please discuss with your doctor any medications
(including over the counter pills or liquid not ordered by the doctor) you have been taking at home if they are not listed above.
KEEP THIS FORM AND BRING IT WITH YOU TO ALL FOLLOW-UP DOCTOR APPOINTMENTS
Figure 2 The American Heart Association Get With the Guidelines heart failure discharge tool.19
Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; CHF, congestive heart failure; CM,
case manager; info, information; MD, physician; rehab, rehabilitation; RN, registered nurse.

therapeutic plan is different from

successfully educating patients and
their families. Patients and their
families should be treated as partners
in learning, not as pupils. If patients
feel engaged in the discussion and
their learning needs are assessed,
they may feel that the information
is more pertinent to their situation.
Teaching sessions should not be a
1-way communication session, but
should engage patients in identifying
their learning needs.25 Nurses who
teach patients should receive training
to ensure that the educational information taught is consistent among
all staff members. If the information
varies among the staff, patients and
their families can become confused.
Hospitalized patients may be
anxious about their disease and may
be concerned about their ability to
perform self-care once they are home.
Plenty of time should be allowed for
patients to ask questions as they
digest the new information. Paper
and pencil should be available at the
bedside for patients to write down
questions as they think of them.
Patients and family members should
be given a telephone number that
they may call to speak to a nurse if
they have any questions or problems
after discharge. Knowing that they
will receive follow-up home visits or
telephone calls may allay their anxiety and fears and allow patients to
absorb information more readily.
An articulate and fluent translator should be included in teaching
sessions when patients do not have
command of the English language.
The translator should be available
if a patient has questions later. Cultural differences may impede the
learning process. Dietary preferences may be somewhat different
for patients of different cultures, and

flexibility should be given to allow
patients to maintain their cultural
differences yet remain within healthy
parameters. If possible, a dietitian
should be involved to help patients
select foods that are acceptable to the
patients palate but low in sodium.
Foods such as soy sauce or tomato
salsa are high in sodium, and every
effort should be made to find lowsodium substitutes.
Educational interventions should
be specifically tailored for patients
and their families and should target
their particular barriers to learning,
such as functional and cognitive
limitations, misconceptions, low
motivation, and low self-esteem.25
The reasons for difficulty in following a prescribed regimen are multifactorial, but possible barriers to
self-care and optimal adherence may
include a complex medication regimen that is confusing to the patient,
cognitive impairment that makes it
difficult for the patient to remember
instructions, or the lack of motivation to follow discharge instructions.
Complex Medication
Regimen
Patients with heart failure are
often discharged with complex
medication regimens.26 Despite the
best intentions of practitioners,
patients understanding of the reason for each medication may be
low, and their ability to follow therapeutic instructions may be limited.
Noncompliance can be as high as
64% for medication and 22% for
diet.27 In a retrospective study28 of
1031 admissions for heart failure,
noncompliance with medications
and diet led to sodium retention
and was the causative factor in 55%
of the admissions. One-third of the

patients were noncompliant with
medications, diet, or both. In a study29
of 220 patients with multiple hospital admissions, the rates of noncompliance with medication, smoking
cessation, and abstaining from alcohol were as high as 64%, 69.5%, and
71%, respectively. Compliance may
be increased by improving patients
understanding of the importance
of the therapy and by streamlining
therapy through the use of oncedaily agents to reduce the complexity of pill-taking regimens.30
Cognitive Impairment
A patients ability to understand,
remember, and apply what he or she
was taught at discharge is another
large barrier. Elderly patients often
have comorbid conditions in addition to heart failure that can make it
difficult to understand and comply
with therapy. The incidence of cognitive impairment among patients
more than 65 years old who have
heart failure is high compared with
the incidence in younger patients,31
indicating that education of elderly
persons is a challenge. Cognitive
impairment may include short- or
long-term memory loss, dementia,
or attention deficit. In a study of
recall of recommendations and adherence to advice among patients with
heart disease, Kravitz et al32 found
that patients who did not recall the
instructions had a much greater risk
of noncompliance with medications
and diet than did patients who
remembered the instructions. Interestingly, patients whose physicians
counseled them about lifestyle
changes and medications were significantly (P<.05) more likely to
recall the recommendations during

a follow-up telephone interview.

Unfortunately, even among patients
who recalled the advice, the noncompliance rate with smoking cessation remained high.
Cline et al33 examined the extent
of noncompliance with prescribed
medication in elderly patients with
heart failure and reviewed the
extent to which patients recalled
information given about it. All
patients received standardized verbal and written information about
their medication, but only 12 (55%)
could correctly name what medication had been prescribed, 11 (50%)
were unable to report the doses
prescribed, and 14 (64%) could not
remember what time(s) the medication was to be taken.
To overcome memory issues, we
must ensure that all instructions
and advice verbally communicated
to patients are also provided in a
written format that patients can
take with them to share with family
members and refer to later. Family
members should be included in the
educational session so that they hear
the information and can reinforce
the instructions once the patient is
at home. If the patients friend or
family member who assists in
preparing the weekly medications
cannot attend a teaching session or
an appointment when medication
changes are discussed, a note explaining the changes should be sent home
with the patient. Even better, a telephone call to the person who oversees the patients medications will
prevent confusion or medication
errors. If a patient with cognitive
impairment does not have a family
member to assist with medications,
it may be helpful to contact the
patients local pharmacist, home
health nurse, or physical therapist

to clarify changes in medication. Any
health care professional who has
regular contact with a patient can
help in evaluating whether the patient
is taking the medications correctly.
A list of medications and when
to take them should be in large print,
and patients should be instructed to
place that list prominently in the area
where daily medications are stored.
Weekly pill containers with 3 compartments per day for morning,
afternoon, and night doses help
patients remember if they have taken
their medications earlier in the day.
Refrigerator magnets with information about signs and symptoms of
worsening heart failure and the
telephone number that the patient
should call if those symptoms occur
can serve as easily accessible daily
reminders. Pictures of foods to avoid,
such as high-sodium foods, should
be available for patients to keep near
the patients grocery shopping list.
Follow-up telephone calls or home
visits may help patients remember
and follow important discharge
instructions. Charts that specify the
time of day for each medication dose,
either with the use of a clock depicting the time or with doses scheduled
around meals, may enhance patients
ability to take pills at the correct
time of day (Figure 3). Pictures of
each pill, which can be found in many
medication books or online, can help
patients identify their medications
and may reduce medication errors.
Lack of Motivation
Patients difficulty in following
recommendations for diet, exercise,
and smoking cessation may be due
to lack of motivation and/or selfcontrol. An increase in knowledge is
not necessarily accompanied by

concomitant changes in compliance
behaviors. Poor physical capacity,
fatigue, and depression and anxiety
are common among patients with
heart failure,25 and all these factors
can lead to lack of motivation and
low interest in learning how to perform self-care. Ni et al24 reported
that although most elderly patients
with heart failure confirmed the
importance of restricting sodium
intake and limiting fluid consumption, less than half reported always
avoiding salty food, and an equally
low percentage did not closely monitor daily weight or fluid intake. This
type of noncompliance indicates the
need for education about the importance of dietary restrictions and
potential consequences of nonadherence. Effective communication
between patients, their families, and
the health care team may help minimize the difficulties associated with
dietary restrictions.
Health care providers may think
that a broad statement such as
remove salt from your diet or
weigh yourself every day is sufficient education. But important
aspects of communication are left
out of instructions like these, such
as why the change is important, specific details, and examples of how to
go about these lifestyle changes.2
The poor taste of low-sodium food
may also be a large barrier.34 Eliciting the assistance of a clinical dietitian for strategies that help patients
and caregivers find special food items,
plan menus, adjust recipes, and
alter the preparation of food can be
of great benefit.2,35 Helping a patient
plan meals and prepare a grocery
list with appropriate low-sodium
foods will offer real-life ideas and

PATIENT MEDICATION CHART

Heart Failure Clinic
Patients name:
Date
Medication
Dosage
Figure 3 Patient medication chart with clock.
suggestions. Cookbooks and Web

sites with low-sodium recipes can be
helpful to patients and their spouses
as they plan meals (Table 2). Lists of
foods to avoid, foods to enjoy in
moderation, and foods that are
within dietary guidelines should be
readily available for patients, along
with lists of substitutes or alternatives to high-sodium foods.
Although smoking can contribute
to increased risk for multiple hospital admissions, most patients lack
motivation to stop smoking cigarettes.29 Despite medical counseling
and awareness that smoking induces
signs and symptoms of heart failure,
patients who have been hospitalized
often continue to smoke. Although
smokers may be instructed to quit,
they may not be provided with the
proper counseling or referral to a
program or technique that would
Results of studies24,37 on alcohol use

assist them.36 Education and counseling sessions to promote behavior
among patients with heart failure
change, referral to smoking cessation
indicate that 25% to 40% of patients
programs, and recommendations to
with heart failure do not understand
use nicotine replacement substances
the risks of alcohol consumption.
may be key to helping patients with
Efforts to educate patients about the
nicotine addiction. Medications
detrimental effects of alcohol on
that promote smoking cessation,
cardiac function should be reinforced,
such as bupropion or varenicline,
and resources should be provided
should be used with extreme caution,
that can facilitate alcohol-withdrawal
and patients
should be
Table 2 Web sites offering low sodium recipes and food
closely monisuggestions
tored during
www.lowsaltfoods.com
therapy.
www.alsosalt.com/lowsodiumfoods.html
Similar
http://yourtotalhealth.ivillage.com/hungry-girl-low-sodium-food.html
techniques
www.dinewise.com/low_sodium
should be used
http://www.americanheart.org/presenter.jhtml?identifier=572
in patients who
are at risk for
www.hfsa.org/pdf/module2.pdf
continuing to
http://www.hy-vee.com/health/health.asp
consume alcohol www.drugs.com/cg/2-gram-sodium-diet.html
after discharge.

efforts. Support group therapy and

alcohol cessation programs may offer
support to patients who find it difficult to stop consuming alcohol.
Motivation for making behavioral
lifestyle changes may be low in
patients who are not ready to commit to making those changes. Despite
education on lifestyle changes that
are necessary when living with heart
failure, many patients are not ready
to learn how to manage their illness.
Some patients are more prepared
than others to hear the information
and make the appropriate lifestyle
changes. For that reason, it is important to determine each patients
level of readiness to make lifestyle
changes and then individualize the
educational sessions to the patients
level of readiness.38,39 For instance, if
a patient states that he or she does
not wish to follow a low-sodium
diet, simply handing the patient
written information on that topic
may have limited benefit. However,
exploring patients dietary preferences with them and tailoring recipes
and spice suggestions may offer
appealing ideas to patients. If a
patient enjoys foods cooked with
garlic salt, perhaps a combination
of garlic powder and onion powder
will be pleasing to the patient.
Patients should be encouraged to
experiment with low-sodium spices
that suit their personal tastes.
Methods of Discharge
Instruction
The methods and delivery of
patient education are varied and
may be important to outcomes.
Education of patients consists of 5
steps, beginning with assessment
of a patients knowledge, learning
abilities, learning styles, cognitive
level, and motivation.25 Next, the

patients learning needs and barriers
to learning must be determined. The
third step includes discussion with
the patient to plan the educational
intervention and set goals. In the
fourth step, the education and information is delivered to the patient
and the patients family as planned.
The last step includes evaluation of
the learning process. Strategies that
fit with the patients learning styles,
cognitive level, and motivation by
using tailored interventions offer a
directed way to enhance compliance
among patients.6,7,23,25-27,29,30,34,40-45 Practical ideas for improving patients
adherence are listed in Table 3.
Nurses are crucial to the success of
education and can increase the
probability of optimal discharge
instruction and better outcomes by
using better education strategies.23
Written Materials
Patients with heart failure recognize the importance of discharge
education. When asked about what
information is important, patients
ranked information on medication
and signs and symptoms as most
important, followed by general education about heart failure, risk factors,
prognosis, activity, psychological
factors, and diet.46-48 The method of
teaching patients varies from patient
to patient, depending on multiple
factors. Patients educational level
dictates their ability to comprehend
written information, and poor
visual acuity limits the benefit of
written materials. Language barriers
must be considered in nonEnglishspeaking communities. All printed
material must be written at an appropriate reading level that will meet
the needs of a wide variety of patients.
Researchers in one study49 showed

that an educational intervention
including written materials specifically directed at patients with low
literacy (less than ninth-grade literacy level) and supportive phone calls
was associated with improvements
in self-care behaviors and signs and
symptoms related to heart failure.
One-on-One Sessions
One-on-one sessions between a
nurse or multidisciplinary team
member and a patient are an important component of education at discharge. In a trial50 of 223 patients
with heart failure, researchers compared the effects of a 1-hour, one-onone teaching session with a trained
nurse educator with the effects of
the standard discharge teaching
done by the staff. Patients in the
education group also received a copy
of the treatment guidelines for heart
failure written in nonmedical, patientfriendly language. Patients receiving
the educational intervention had a
35% lower risk of rehospitalization
or death. The intervention patients
also reported increased self-care
practices. Compared with controls,
they were more likely to weigh
themselves daily (66% of intervention
patients vs 51% of controls, P=.02),
follow a sodium-restricted diet (32%
vs 20%, P = .05), and stop smoking
(97% vs 90%, P = .03).50
A prospective, randomized trial51
was conducted to determine the effect
of a formal education and support
intervention on 1-year readmission
or mortality and costs of care for
patients hospitalized with heart failure. The intervention consisted of
an experienced cardiac nurse conducting an hour-long session covering each patients knowledge of the

Table 3
Key strategies for providers and patients for improving education and involvement/adherence of patients
Strategy
Evidence or rationale supporting strategy
Practical implementation
Provider led
Nurse- or pharmacist-led disease
management interventions
Initiate or increase current involvement

Readmission rates for heart failure significantly
in a multidisciplinary program
decreased when a cardiac nurse educator was used to
coordinate an inpatient heart failure education program
with comprehensive discharge planning23
90 days after discharge, multidisciplinary intervention
reduced all-cause admissions by 44% compared with
usual care; heart failure admissions decreased by 56%40
In-hospital initiation of
medication
At 60 days, 91.2% of patients started on -blockers

before discharge remained on therapy, compared with
73.4% who started taking the drugs after discharge41
Improvement in communication
between provider and patient
about medication
Improved communication with patients with heart failure Confirm that patient has been fully
before discharge resulted in a 16% reduction in morinformed about medication before distality, 14% decrease in readmissions, and 31%
charge
decrease in heart failurerelated rehospitalization, with Provide written educational material
1 life saved for 34 patients treated42
Reduction in the complexity of

drug regimens
Patients on once-daily therapy had significantly greater

adherence than did patients on twice-daily therapy43
Combination medications can increase adherence44
Consider once-daily therapy and/or use

of polypharmacy if appropriate
Avoidance of medications with

known adverse effects
Adverse effects can decrease quality of life and prevent

patients from adhering to treatment with some
agents30
Provide patient with a list of possible

adverse effects from medications;
include discussion of sexual dysfunction as a potential adverse effect
Discussion of adherence during

normal follow-up care
In 39% of encounters, providers did not ask patients

about the medications patients are taking45
Confirm that patient has been fully

informed about medication at follow-up
Heightened awareness of the

possibility of poor adherence
Education level, insurance, socioeconomic status,

advanced age, cognitive impairment, and depression
may be predictive of poor adherence30
Note patient-specific barriers or special

circumstances
Awareness of limitations: vision,

hearing, mobility, and cognition
(memory)
Use of larger text and pictures, a mild exercise plan,

slower teaching pace, increased repetition of information, and involvement of family can lessen the impact
of patients limitations25
Tailor education method and/or material

to the individual patients needs or
limitations
Awareness of low motivation

(evaluation of fatigue and
depression) and low self-esteem
A nonthreatening climate, positive feedback, and a trust- Provide more context about why the
ing relationship between health care provider and
patients heart failure plan is important
patient can improve a patients self-esteem25
Encourage treatment of fatigue and
depression
Use of multiple educational

materials
Patients with heart failure are often discharged with

complex treatment regimens26
Provide written material, brochures,

booklets, newsletters, videos, CDs,
and Web-based programs to increase
patients exposure to material about
heart failure
Use of multidisciplinary
involvement
A team approach to patient education can reduce hospital

readmission rates and costs22
Include dietitian, respiratory therapist,

physical therapist, pharmacist, and
social worker in discussions
Lack of adherence to medications, failure to follow a

salt-restricted diet, and delays in seeking medical
attention are primary reasons for the high rate of
rehospitalization among patients with heart
failure6
Advise patients to write down questions

in order to remember them and ask
when the physician or nurse is present
Suggest that patients attend support
groups or teaching sessions, read all
literature that is provided, and watch
all CDs or videos
Assess patients knowledge of medications

before discharge
Provide prescriptions for medications at
discharge
Patient led
Active participation in disease
management
Continued

Table 3 Continued
Strategy
Evidence or rationale supporting strategy
Practical implementation
Patient led
Overcoming a reluctance to tell
provider about adherence
problem
Noncompliance with medication and diet can be as high

as 64% and 22%, respectively27
Noncompliance rates with smoking cessation and
abstaining from alcohol can be as high as 69.5% and
71%, respectively29
Encourage patients to be open and

honest in all discussions with health
care providers
Understanding basic aspects of

disease
Greater medication knowledge, skills, and adherence are

associated with fewer visits to the emergency department7
Encourage patients to ask health care

providers to explain the disease and its
consequences, and to ask for referral
to other educational sources (eg, Web
site) for more information
Understanding complex dosing

schedules
Strategies to improve dosing schedules include the use

of pill boxes to organize daily doses, asking the physician if the regimen can be simplified, and cues to
remind patients to take medications30
Provide patients with a take-home medication chart showing timing of dose

and photograph of tablets
Need for family support
Educational interventions involving patients and their family

members can be effective in improving adherence30
Suggest that patients bring family members to follow-up and share care plans
with them
illness, the relation between medications and illness, the relationship

between health behaviors and illness, early signs and symptoms of
worsening heart failure, and when
and where to obtain assistance.
Patients understanding of the topics was assessed and reviewed to
provide information about gaps in
patients knowledge for the nurse to
address. In subsequent follow-up
sessions (by telemonitoring), the
nurse reviewed knowledge and
provided support for patients to
reinforce the initial educational
foundation, theoretically by
empowering patients and offering
strategies to improve adherence.
The intervention was associated
with a 39% decrease in the total
number of readmissions.51
In another study,52 179 patients
with heart failure were randomized
either to usual care or to a nurse
education initiative (consisting of
intensive, systematic, and planned
education by a study nurse about
the consequences of heart failure in
daily life) both in the hospital and 1

week after discharge. In addition to
evidence-based education such as
recognition of warning signs and
symptoms of worsening heart failure, problems of individual patients
such as social interaction, sexual
function, and limited access to the
general practitioner were discussed.
During the hospital stay, the study
nurse assessed each patients needs,
provided education and support to
the patient (and the patients family), gave the patient a card listing
the warning signs and symptoms,
and discussed discharge. Within 1
week after discharge, the study
nurse telephoned the patient to
assess potential problems and reinforced and continued education as
warranted. One month after discharge, patients from the intervention group reported complying with
14 of the 19 self-care behaviors, vs
12 behaviors for the control group.
The increase in self-care behavior
from baseline to 9 months was significant in the intervention group
(t=4.9, P<.001) but not in the control group (t=1.9, P=.06).
Social Support
Support from people close to a
patient with heart failure is often
important to success. For example,
patients who are married tend to
have a greater knowledge about their
disease.24 The self-management of
dietary restrictions is difficult and
usually occurs within the context of
family; therefore, a family education
intervention was tested for the effect
on improving self-management
related to sodium intake.53 Patients
with heart failure and a family
member received either (1) in-depth
education and counseling (in both
verbal and written form, a video on
heart failure care, and individualized
dietary discussion and feedback to
promote knowledge as well as selfefficacy in selecting and preparing
low-sodium foods) by a nurse expert
and a dietitian or (2) the same indepth education, counseling, and
feedback by the same research nurse

and dietician plus 2 additional sessions focused on enhancing family

support and patients choice through
communication and empathy. Selfreported dietary sodium intake and
24-hour urinary levels of sodium, a
reflection of dietary sodium intake,
were measured at baseline and 3
months after the intervention.
Both groups had decreases in
dietary sodium intake and sodium
level in the urine at 3 months; however, the group with the additional
2 sessions that focused on family
support had greater decreases in the
levels of sodium in the urine (mean
[standard deviation], 3438 [1205] mg
decreased to 2612 [1255] mg in the
intervention group vs 2945 [1606] mg
decreased to 2932 [1747] mg in the
control group) and had a greater percentage of those with 15% decreases
in levels of sodium in the urine (67.9%
of intervention patients vs 40.7% of
control patients, P=.04).
Motivation
A motivational intervention is
one that increases the likelihood of
a person choosing, continuing, and
completing a change strategy. A
behavioral management intervention was designed to augment usual
care and to help patients with heart
failure establish healthier behaviors
to improve their quality of life.54
Two advanced practice nurses
facilitated the intervention, which
included group classes and individual follow-up with telephone calls.
The intervention was evaluated by
receiving feedback from the participants about their satisfaction and
anecdotal information from the class
leaders. Patients reported high satisfaction with the intervention. When
motivation was defined as choosing,
continuing, and completing a behavioral change, the intervention was

partially successful; patients were
able to choose and begin a change
strategy but did not follow through
in continuing and completing the
strategies. Readiness to change behavior and perceived control should be
considered for future studies to
examine how these factors influence
learning, motivation, and behavioral
change. Research with a motivational
model may facilitate behavioral
change and improve the quality of
life of patients with heart failure.
Education of Patients
After Discharge
Follow-up after hospitalization
can reinforce the education that was
delivered at discharge. In a study55 of
home-based care after discharge, the
intervention involved a nurse visiting the patient once at home after
discharge to teach the patient about
heart failure and the medications. A
reduction in heart failure events (38
vs 51; P=.04) and unplanned readmissions (68 vs 118; P=.03) was seen
in those patients receiving the followup visit at home compared with the
control group.55 In a study56 of 106
patients assigned to either follow-up
at a nurse-led heart failure clinic or
usual care, fewer patients in the
intervention group than in the control group died or had to be admitted
to the hospital after 12 months (29
vs 40; P=.03). All patients answered
a questionnaire after 3 and 12 months
to evaluate their self-care behaviors,
and the intervention group scored
significantly higher than the control
group did (P=.02 after 3 months
and P=.01 after 12 months).56
In another study,57 researchers
assessed the long-term effectiveness
of a disease management program

that combined discharge planning,
education, optimization of therapy,
improved communication, early
attention to signs and symptoms,
and intensive follow-up. After 2
years, all-cause death and hospital
admissions for heart failure were
36% lower in the intervention group
than in the usual-care group. Compared with baseline, patients in the
intervention group reported significant improvements in functional
status, quality of life, and rate of
prescription of -blockers.
Telephone monitoring is a possible tool to reinforce education
and assess patients status. Remote
titration of the dose of -blocker
carvedilol by advanced practice
nurses was studied in patients with
heart failure.58 Before therapy, the
nurses instructed patients about the
side effects of -blockers, how to
take a pulse, and monitoring weight.
Three times a week, patients reported
their weights, vital signs, and symptoms to the nurses by phone. The
advanced practice nurses counseled,
educated, and reminded patients to
increase the dose of carvedilol every
2 weeks until the target dose was
reached. As a result of this intervention, 96% of patients reached a therapeutic dose (6.25 mg twice daily),
and 71% of patients reached target
doses of 25 mg twice weekly in
approximately 8 weeks. No hospitalizations for heart failure occurred
during this period.58 Another study59
included 14 randomized controlled
trials (4264 patients) of remote
monitoring (telemonitoring and/or
structured telephone support) to
determine if such monitoring
improved outcomes in patients with
heart failure. Remote monitoring

programs reduced the rates of hospital admissions related to heart

failure by 21% and the rate of allcause mortality by 20%. New technologies such as telemonitoring can
be helpful tools to improve education but should be used as an addition to a comprehensive educational
discharge program.
Comprehensive Approach
Although they may have been
focused on a single tactical method,
most of the studies mentioned
investigated the value of a comprehensive educational program that
included a combination of inpatient
and outpatient education. The more
comprehensive an educational strategy is, the better. For instance, in
one study40 patients with heart failure were randomized to receive either
usual care or a nurse-directed, multidisciplinary intervention that
included a review of patients conditions and their medications, home
visits, dietary advice, and telephone
calls. At follow-up 90 days after
discharge, the multidisciplinary
intervention had reduced all-cause
admissions by 44% (P = .02) compared with usual care, and admissions for heart failure were reduced
by 56% (P = .04).
In a study23 of the potential benefits of comprehensive management
of elderly patients with heart failure,
the intervention consisted of an
d t
To learn more about providing care for
patients with heart failure, read EvidenceBased Nursing Care for Patients With Heart
Failure by Nancy Albert in AACN Advanced
Critical Care, 2006;17(2):170-183. Available at
http://www.aacnclinicalissues.com.
experienced cardiac nurse educator

who coordinated a targeted education
program for inpatients with heart
failure coupled with comprehensive
discharge planning and immediate
outpatient reinforcement through a
coordinated nurse-managed home
health care program. After 30 to 60
days, the readmission rate for heart
failure in the usual-care group was 6
times the rate in the intervention
group. After 6 months, the readmission rate in the usual-care group
was nearly 4 times the rate in the
intervention group (44.2% vs 11.4%;
P=.01).
In another study60 of 165 hospitalized patients with heart failure
who were randomized to either a
comprehensive nurse intervention
or usual care, the nurse intervention
included educating patients about
the disease and its treatment, including training in how to adjust dosages
of diuretics, as well as home visits,
telephone contact, extensive monitoring of each patient, and up-titration
of medication. Patients in the nurse
intervention group had fewer allcause admissions than did patients
in the control group (86 vs 114, P=
.02), had fewer admissions for heart
failure (19 vs 45, P<.001), and spent
significantly fewer days in the hospital for heart failure (mean, 3.43 days
vs 7.46 days, P = .005).
Summary
Although much of the literature
has been devoted to programs to
improve the process of care, less
attention has been paid to the comprehensive strategies provided by
specially trained nurses that have
improved outcomes for patients with
heart failure. When studied in the
context of multidisciplinary teams,
specialists contribute significantly

to improving outcomes. In a review
of 29 trials of multidisciplinary
management programs, McAlister
et al61 found that 1 of the 3 elements
crucial to a successful program is
the use of nurses who are knowledgeable about heart failure.
Providing comprehensive discharge education to patients with
heart failure is essential to improving outcomes, and cardiac nurses
are in a position to take on the role
of educators. Patients with heart
failure should understand their condition, their medications, and when
to seek medical treatment. As more
is learned about the important effects
of education and self-care on patients
outcomes, the need to move away
from the traditional view of patients
as passive recipients of information
is clear. Patients should be viewed
as active partners in the management of their health.
Cardiac nurses play a fundamental role in the educational
process and can be the primary
practitioners who teach and evaluate patients self-care abilities,
which include weight monitoring,
sodium and fluid restrictions, physical activities, regular medication
use, monitoring signs and symptoms of disease worsening, and
early search for medical care. Cardiac nurses should strive to understand the barriers to patient
adherence and self-care and learn
strategies to educate patients to
overcome those barriers. A discharge management program led
by a cardiac nurse that incorporates
the latest evidence, guidelines, and
tools can substantially improve the
level of care for patients with heart
failure. CCN

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14.
None reported.
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Hospital Discharge Education for Patients With Heart Failure: What Really Works
and What Is the Evidence?
Sara Paul
Crit Care Nurse 2008, 28:66-82.
2008 American Association of Critical-Care Nurses
Published online http://www.cconline.org
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Hospital Discharge Education For CHF

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Clinical Article

Hospital Discharge Education

active partners in the

understand the barriers to self-care and

mates, 54% of readmissions may be

66 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

Lifestyle changes required in the self-management of heart failurea

(standard deviation) of 0.22 (0.73)

recognize the importance of education and recommend that patients

CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 67

Heart failure patients discharged home.

Administrative data and medical records

with heart failure receive written

reviewed to determine the percentage

Diet: 70% (range, 58%-94%)

68 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

were not documented. More recently,

Does Compliance With

reduce hospital stays and improve

whether receipt of this measure was

Educational Tools and a

CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 69

provision and quality of discharge

were 4 times higher in the group

70 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

CARDIOVASCULAR DISEASE DISCHARGE INSTRUCTIONS

Does not smoke - or - Has not smoked in more than 12 months

AMI/CHF Discharge Packet Given

Home Exercise Program Instruction Provided

Drug info/food/drug interaction info provided

Cardiac Rehab Information Provided

Daily Weights Instructions Given-See back

Cardiac Rehab Ordered

Diet __ Low Sodium, Low Cholesterol, high fiber

Your Total Cholesterol: ___

Resources on back reviewed

Driving Instructions Given

May Return to Work on (date) ___________________

Activity: Light activity until follow-up appointment

Dr.: ___________________________ Phone: ___________________________________ Date: ___________

Dr.: ___________________________ Phone: ___________________________________ Date: ___________

Home Care Agency: _______________________________ Phone: ___________________________________ Date: ___________

CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 71

therapeutic plan is different from

for patients of different cultures, and

of the admissions. One-third of the

72 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

a follow-up telephone interview.

health nurse, or physical therapist

not necessarily accompanied by

74 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

PATIENT MEDICATION CHART

Figure 3 Patient medication chart with clock.

suggestions. Cookbooks and Web

Results of studies24,37 on alcohol use

CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 75

efforts. Support group therapy and

level, and motivation.25 Next, the

Researchers in one study49 showed

76 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008

Evidence or rationale supporting strategy

Initiate or increase current involvement

At 60 days, 91.2% of patients started on -blockers

Dr.: ___ Phone: _ Date: _

Dr.: ___ Phone: _ Date: _

Home Care Agency: _______ Phone: _ Date: _