1. Dunlap, Cathy Lee MS, RN
  2. Upper, Toni M. AD, RN

Article Content

HEART FAILURE (HF) is a chronic, progressive disease that affects nearly 5.8 million people in the United States and leads to frequent hospital admissions and high mortality.1 Patients with HF are on every hospital unit and in all settings where nurses care for patients.


This article focuses on how we improved patient education for patients with HF. Providing patient education for those at risk for HF exacerbation to prevent readmission is a core measure of the Centers for Medicaid Services and The Joint Commission.2 Our first step was becoming aware that we had a problem.


Lack of HF education

When the HF outcomes manager notified our unit that we'd fallen below the standard for documenting HF education, we brainstormed about possible reasons. Most of our patients are undergoing procedures related to various cardiac issues, such as myocardial infarction, dysrhythmias, and syncope; fewer than 20% of our patients are admitted with a diagnosis of HF.


With our focus on caring for patients before and after cardiac procedures, our patient education centered on postprocedural and/or cardiac device care, such as pacemakers and implantable cardioverter-defibrillators (ICDs). In following up on the need to improve education for our patients with HF, it became clear that nurses needed more information on how to identify patients who also need HF education.


Our review of the literature revealed research studies addressing the importance of patient education to improve HF self-care management. We didn't find any research studies describing the best method to identify patients at risk for HF. As a result, several direct care nurses decided to develop a research study with a structured approach to identify patients needing HF education.


The six elements for the diagnosis of HF established by the American College of Cardiology Foundation/American Heart Association became our method of identifying patients with HF.2 These elements included:


* dilated cardiomyopathy or history of left-ventricular systolic dysfunction


* markedly reduced ejection fraction (EF)


* placement of an ICD for an EF of 30% or less


* an EF of 35% or less and cardiac dyssynchrony


* B-type natriuretic peptide (BNP) greater than 100 pg/mL


* drug classifications including angiotensin-converting enzyme inhibitors, beta-blockers, angiotensin II receptor blockers, diuretics, and digoxin.3



In addition, chest X-rays (CXRs) can demonstrate cardiomegaly, pleural effusion, and pulmonary congestion that can indicate HF.3


These six elements became our "triggers" for identifying patients who needed HF education. Further assessment was needed if one of the CXR abnormalities was identified, if the patient's BNP was greater than 100 pg/mL, and/or if the patient was using any of the medications in the categories listed.


Methods used

Our research design was quasi- experimental; our research question was "Will the use of HF triggers increase patient education by nurses?" A convenience sample included the 59 RNs on our 50-bed cardiology unit.


Before collecting data, we provided a 1-hour continuing-education (CE) program on HF and principles of adult learning to all nurses on our unit. Then, we collected baseline data for 3 months. Using a specially designed data collection sheet, nurses were asked to record HF content taught and patient-education resources used.


The two study interventions were then implemented: a 1-hour CE program that focused on each of the triggers and how to use them to identify patients needing HF education, and an "HF extravaganza."


To encourage participation in the CE programs, we made a DVD available for nurses to view either at work or at home. A folder for each CE program containing handouts, articles, and pocket cards was placed in the mailbox of every nurse who hadn't attended either program.


To encourage attendance at the HF extravaganza, a non-CE event, we created the atmosphere of a fair. The HF extravaganza consisted of a 3-foot by 4-foot trifold poster for each trigger, including HF resources for nurses and patients/families. The HF extravaganza was available to nurses 24 hours a day for 1 week. We decorated posters and tables with balloons, confetti, and garlands. Each table also had handouts, candy, and favors. Nurses who completed a quiz about information on the posters were eligible for daily prize drawings and one grand prize drawing at the end of the week.


Of 59 RNs, 34 (58%) participated in the baseline CE program. Twenty RNs (34%) attended the CE program that focused on using the triggers for HF education. Thirty-five nurses (59%) participated in the HF extravaganza. A total of 45 of 59 nurses (76%) participated in at least one of the educational interventions.


Following the educational interventions, we again collected data for 3 months. Using a specially designed data collection sheet, nurses were asked to record each trigger identified for HF education, the specific HF content taught, and any patient-education resources used. During this period, we continued to engage nurses in the study in various ways. Reinforcements included posters, a handout with key points from the HF extravaganza, and an HF-based word search with drawings for small prizes.


Positive study results

We used descriptive statistics to compare baseline and postintervention data. The number of nurses who taught patients about HF increased from 16 to 23; although this increase was clinically significant, it didn't reach the level of statistical significance. However, the number of patients taught about HF increased from 20 to 44, a statistically significant increase of 115%.


All HF elements taught increased after the educational interventions:


* reducing dietary sodium, from 15 to 35 (133%)


* measuring daily weights, from 15 to 32 (113% )


* medication information, from 12 to 29 (142%)


* importance of follow-up, from 9 to 23 (156%)


* physical activity, from 9 to 20 (122%)



All increases were statistically significant except for teaching about physical activity. The use of HF patient- education resources also increased, but the increase wasn't statistically significant.


From these results, we concluded that our protocol for using the triggers for HF education was effective in increasing the numbers of patients who received HF education.


We reported the positive results of the study to our unit-shared govern ance council and requested that the triggers for HF education be added to the written shift-to-shift report form for each patient used by all nurses. The report form now includes a section to identify triggers for HF education, in addition to the test and procedure results.


After the results of the procedures are known, nurses are prompted to consider if additional triggers are present. The report form is used to communicate whether HF education is needed and if reinforcement of teaching is indicated. The involvement of nursing management and clinical leaders to make HF education a priority for our unit was important to foster a change in nursing practice.


We collected outcomes data for an additional 12 months. Self-care management teaching increased from 26% (76 of 289) during the first quarter to 46% (148 of 323) during the fourth quarter.


Future implications

Reinforcing the importance of HF education and using the triggers for HF education has been essential to maintaining this change in practice. Ongoing education of current nursing unit staff and orientation of new staff has included additional HF extravaganza offerings. We provide a folder of appropriate handouts to each newly hired nurse. An educational presentation at nursing grand rounds provided an update of HF principles for nurses throughout the facility. This digitally recorded CE program is available via our online learning management system.


The triggers we identified for HF education may be used in any setting to identify patients needing education in HF self-care management. Our goal is to include HF trigger prompts in the electronic medical record as our clinical information system evolves. Any nurse working with adults may encounter patients who need HF education. You too can use the HF triggers to improve patient education on HF.



The authors want to express appreciation to the IRB #1 at Dublin/Grady/Riverside and the Riverside Methodist Hospital Research Foundation. The authors also appreciate the assistance of the Nursing Research and Excellence Department, especially Gretchen Glasgow, PhD, RN, for proposal development and Jeanette Chambers, PhD, RN for manuscript preparation. Completion of the study wouldn't have been possible without the extraordinary support of Angela McCloskey, MBA, RN, Nurse Manager, 3 Heart Interventional Cardiology Unit, Riverside Methodist Hospital.




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2. Burke CA. Reducing readmissions for patients with heart failure. Nursing. 2010;40(9):12-13. [Context Link]


3. Jessup M, Abraham WT, Casey DE, Jr, 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 Foundation/American Heart Association Task force on Practice Guidelines: Developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):1977-2016. Epub 2009 Mar 26. [Context Link]