Decreasing Heart Failure Readmissions

Submitted by:Written by: Irene Sours, RN, WCC, ICP, Nurse Consultant
Overall, 30 day re-hospitalization rates for residents of long term care facilities have steadily risen in the United States. This is largely due to the average hospital length of stay has been reduced and patients discharged to long term care facilities sooner than in the past.
A frequently observed example is a resident with arteriosclerotic heart disease in addition to congestive heart failure that requires close observation by all staff for signs of decompensating, abnormal fluid balance or adverse effects resulting from prescribed medication.
Case managers/admission coordinators and nursing staff play key roles in reducing heart failure readmissions, beginning with admission to the long term care facility.  Reviewing the resident’s medical information prior to arrival is vital and reviewing again after admission is just as important.
  • Link each medication with a diagnosis, appropriate clinical and laboratory monitoring and document.
  • Identify weight parameters and protocol for weight gain.
  • Identify sodium restricted/specialized diet.
  • Establish physician visit within 3 to 5 days of hospital discharge with appropriate primary care or specialist physician.

There are several basic steps in developing effective chronic disease management and care within the facility. An initial step is to develop materials and processes that describe the signs and symptoms in easy, understandable terms to ensure residents, families and staff (i.e., STNA, activity staff, dietary aides, housekeeping, etc.) can communicate their understanding of the basic disease process.
Key points regarding CHF may include:
  • Congestive heart failure means the heart is not pumping enough blood to meet the body’s needs.
  • Blood may back up in the lungs causing shortness of breath and increased coughing
  • Blood may also back up in other parts of the body, which can cause swelling in the legs, feet or abdomen.
  • Diminished blood flow in the body may increase fatigue and promote loss of appetite.
Disease monitoring and intervention coordination by licensed nursing staff and STNA’s is crucial. Management of CHF requires regular assessments that are most effective when completed consistently by a nurse and STNA who are knowledgeable about the resident and their disease pattern. This can be accomplished by regular staff assignments.
Communication of an acute episode to a primary physician can be challenging. A thorough assessment before contacting the physician is paramount. The assessment should consist of the following: collecting vital signs, apical pulse, lung sounds assessment, O2 saturation, allergies, recent change in medication, mental status change, fatigue, etc. By providing the appropriate communication tools and holding competency and practice skill labs will make the licensed nursing staff proficient in providing accurate and timely communication.
Work together with the primary physician and demonstrate nursing staff is equipped with the knowledge and tools to monitor and treat acute CHF episodes at the facility. Effective management of CHF is important for all skilled nursing facilities. Many tools are available, such as INTERACT III or you can develop your own, but remember the key is consistency and education.

Peters, Diane, RN, NHA, MS. Improving care for Residents with Congestive Heart Failure.
AHRQ. Evidence-based Practice Center Systematic Review Protocol Project Title. 

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