Discharge Planning
In-patient management extends beyond haemodynamic monitoring and initiation of medication to planning for discharge and the smooth transition to a community heart failure disease management programme. It is now well recognised that patients are at high risk of hospital re-admission during the first few months following discharge. This has led to recommendations for follow up early in the postdischarge period and ideally within the first one to two weeks.3 Disease management programmes are now established in many European countries. A recent survey of countries of the ESC reported that heart failure clinics are present in 75 % of those countries that completed the survey and that a heart failure nurse specialist was employed in the majority of those clinics.13
Discharge planning commences once the patient is stabilised and discussions include the heart failure specialist team, the patient and, where necessary, the patient’s family. Preparing for discharge requires assessment of social environment into which the patient will be discharged as well as their capacity to self-care. Patients admitted to hospital with heart failure are frequently elderly with multiple comorbidities. They have reduced physiological reserve to adapt to change and stress and may require a period of rehabilitation and supportive community resources in the initial post-discharge phase. In such situations the heart failure nurse co-ordinates discussions to develop a collaborative discharge plan. In a quasi-experimental study in Sweden of 248 elderly patients hospitalised with heart failure Ulin and colleagues report an earlier hospital discharge in patients whose discharge plan was a collaborative process between the heart failure team and social/community team. They report a mean of 6.7 in-hospital bed days compared with 9.2 days in patients who did not receive a co-ordinated discharge plan.14 Such an approach may have particular advantage when hospital discharge is delayed due to social circumstances.
Regardless of age, discharge from hospital is frequently cited as a period of high anxiety for both patients and their families. A coordinated care plan that estimates time to euvolamia and commencement of heart failure medication can be communicated and discussed at an early stage and so help prepare both the patient and their family for discharge.
Patient Education
The in-hospital period is also an ideal time to provide education about heart failure, its monitoring and management. It is possible that some hospital admissions are preventable if worsening heart failure is recognised early; some patients and family wish to be involved in self-care e.g. by monitoring their condition, recognising significant change and taking appropriate action. They should be introduced to these concepts during the in-patient stay. There is often a mismatch between a patent’s understanding of their heart failure management and the information provided by the health professional. For example, the Euroheart failure survey reported that patients recalled only 46 % of the self-care advice given15 whilst Ekman and colleagues, in a substudy of the COMET study, reported that adherence to medication was associated with patient beliefs about their medication.16 Results such as these point to the complexity of providing the patient with education for self-care and are recognised in the current focus on individualising patient education. A patient’s capacity to learn and retain new information may be reduced whilst hospitalised, in part due to higher levels of anxiety and cognitive dysfunction. It is therefore good practice to use the hospital admission to provide the patient with verbal information that is supported by written material. Some nurses use the ‘teach-back technique’ whereby they ask the patient to repeat, using their own words, the information they have given them.17 This enables the patient to confirm their understanding and the nurse to rephrase any information that is misunderstood. Such a technique involves the nurse and patient in the repetition of information and increases the time the nurse spends with the patient discussing heart failure and its management. It is possible that this increased time spent in patient education provides benefit in terms of knowledge retention and may be particularly valuable when interacting with the person with low educational or health literacy. Both the education provided and the patient’s understanding should be communicated to the heart failure disease management team and should form a basis for ongoing education and support.
End-of-life Care
Mortality is high in patents discharged from hospital following an acute heart failure admission. Despite advances in care about 14 % of patients still die within six months of hospital discharge.18 Various factors are likely to increase this risk such as age, frailty, number of hospital admissions in the preceding 12 months and presence of cachexia.2 The hospital admission provides time to identify patients with a worse prognosis and introduce palliative and supportive measures. Such care actions include providing pain relief, discussions around future care planning and preferred place of death. There is a growing recognition of the need for such discussions and hospitals increasingly provide a palliative care service jointly between the heart failure and palliative care nurse. Where such services exist studies report a reduction in symptom burden and depression and improvements in quality of life.19 Such services also report an increase in advance care planning.20 This may help address the currently reported mismatch between patients’ preferred and actual place of death.