Better education means fewer readmissions
Better education means fewer readmissions
LOS drops 1.5 days, readmissions down 3.3%
Hospital staff at District One Hospital in Fairbault, MN, asked for the community’s help when they embarked on an effort to reduce hospital readmission rates for congestive heart failure (CHF) patients by improving patient education efforts within the hospital.
A continuous quality improvement (CQI) committee was formed when statistics indicated that CHF patients at District One had a high readmission rate, and their length of stay (LOS) was longer than at other hospitals of similar size (88 beds).
According to data compiled from 1993 Medicare admissions for CHF, the readmission rate after 15 days was 15.4% at District One while the hospital’s peer group rate was 12.4%. LOS was 6.1 days at the hospital compared to 5.4 days at hospitals of comparable size.
With the continuum of care from inpatient to outpatient status playing an increasingly important link in keeping readmission rates low, communication between the two entities plays a vital role.
To make sure information was shared and to keep the lines of communication from breaking down, a representative from home health was included on the CQI team.
The inclusion of a public health nurse in CQI efforts proved vital in keeping readmission rates down. ’We started making sure public health knew what we were teaching, and we began having automatic referrals to public health,” says Dawn Conrad, RN, BSN, patient educator at District One.
’Whatever the hospital started to teach, we reinforced when the patient got home,” says Mary Lindahl, BSN, home care supervisor for Rice County Public Health Nursing Service and a member of the CQI committee.
The committee, which was formed in the fall of 1994, disbanded a year later when the results of its efforts proved effective. Readmission rates for CHF patients 15 days following discharge are now at 12.1% and LOS averages 4.6 days.
While the inclusion of public health was an important step in improving readmission rates and LOS, other improvements contributed to the success of the CQI team. These steps included:
1. A staff education program.
District One arranged for a three-hour session on congestive heart failure, featuring a physician from the Rochester, MN-based Mayo Clinic who spoke on the current treatment of CHF. A nurse from the Mayo Clinic spoke on patient discharge teaching, and a dietitian from District One discussed dietary considerations.
Everyone who works with CHF patients was invited to attend the lecture, including staff from:
• skilled nursing facilities;
• public health;
• home care agencies;
• hospital departments, such as dietary and social services;
• board and lodging directors;
• adult foster care attendants;
• physicians.
A total of 90 people attended, an impressive number for a small community, says Conrad. Committee members also looked through professional journals for articles on CHF and made copies available to nurses on the med-surg unit.
2. A community outreach education effort.
The hospital now provides monthly education programs at the local senior center. Topics have included label reading to ensure a low-sodium diet, exercise and pulse reading, weight management, blood pressure control, and microwave cooking. ’The sessions last an hour and are right before lunch so we have a captive audience,” Conrad says.
3. A CHF checklist for patient education.
Inpatient teaching was a little haphazard. Although patients were to view a CHF video, receive a number of handouts, and be taught the symptoms of CHF and how to implement their treatment plan, it didn’t always get done because teaching was not properly documented, Conrad says. Therefore, the committee created a checklist that listed all the information to be covered, including:
• Patient will state a simple explanation of CHF.
• Patient will be able to list the symptoms of CHF:
sudden weight gain, such as two to five pounds in one to four days;
swelling in the ankles, legs, or abdomen;
shortness of breath;
frequent dry mouth;
feeling of extreme muscle fatigue.
• Patient will implement treatment plan involving:
medications listed by name, dose, and indication and be able to state schedule and side effects;
diet changes, such as decreasing sodium intake;
daily weight recorded;
rest and exercise.
• Patient will identify importance of follow-up care, including physician visits and when to report symptoms.
4. Improved patient education handouts.
Patient education materials used before the CQI committee included:
• a pamphlet from the Dallas-based American Heart Association titled Facts About Congestive Heart Failure;
• a congestive heart failure treatment plan that gave details on keeping a daily weight record, planning rest periods, eating a low-sodium diet, exercising, and when to call the doctor;
• a 12-minute video for inpatients on CHF.
Although the materials were effective, Lindahl pointed out some changes that could make it easier for elderly patients to read them. ’We discussed the color and size of the print and the color of the paper,” she says. ’Many of the educational items were in blue print and when someone has a visual problem, it is difficult to read.”
Additional materials now given to the patient include a sheet titled Understanding Congestive Heart Failure, printed by the Zeneca Pharmaceuticals Group of Wilmington, DE, and a booklet for keeping a daily weight record, printed by District One.
5. Home health visits increased.
All CHF patients are referred to public health nursing services and receive three visits the first week they are home. The purpose of the visits is to answer questions, monitor the patients’ physical condition, and make sure they understand their medications and diet.
The home health nurse receives a copy of the patient’s diet sheet and reinforces the dietitian’s teaching efforts. ’Sometimes we go look in the cupboards and say this is OK, and this is not.’ Many were fixing regular frozen dinners, and they are loaded with sodium, so we started recommending some optional foods,” Lindahl says.
The home health nurse also helps patients learn simple exercises that can be done while sitting or standing. Patients receive the exercise sheet in the hospital, but the teaching is reinforced in the home. Severe Minnesota winters keep seniors homebound, so the exercises are important, Lindahl says.
Sometimes the nurses have to show the patients how to weigh each day and track their weight.
District One’s CQI committee for CHF was multidisciplinary. In addition to patient education and public health, representatives from med-surg, pharmacy, nutrition services, social services, quality management, the outpatient clinic, administration, and utilization review were included. A physician also was on the committee.
During a survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, a surveyor commended District One for including representatives from outside the hospital on the committee. He said it was what the Joint Commission was looking for in continuum of care, Conrad says.
Before the CQI committee, there was not a lot of communication between public health and the hospital. Now staff at each facility understand the workload the other carries. ’Patients aren’t in the hospital very long, and when they are there they are so sick the nurses can’t do a lot of teaching. Therefore, we are picking up where they leave off. Before we expected them to do a lot more teaching,” Lindahl says.
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