Evidence-Based Practice Research Project on Patient Education With CHF

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EBP Patient Education

Case Study

Despite the fact that William J. is already 84 years old, he takes pride in following a balanced diet, living an adventurous live, and actively participating in various community activities. This man has never been either tobacco or alcohol-addicted individual because jogging and hockey have always been his hobbies. Moreover, William is a cancer survivor, which is why he takes care of his vulnerable health. In addition, he always spends time with his grandchildren, friends, and wife who look after him and inspire him to exercise regularly and take pleasure in life. However, recently William’s heart started to trouble him for some unknown reasons. William noticed some unknown and strange symptoms, especially continuous complaints of fatigue, shortness of breath, and severe chest pain. The man was worried because these unbearable sores impeded him from following his healthy lifestyle. When William J. went to the primary care physician, the doctor recommended him to get consultation from cardiologists because of the increased risks of heart failure. After detailed physical examinations and several tests, including the blood tests and ultrasound examinations, William was diagnosed with congestive heart failure (CHF). The cardiologist explained William that his aortic valve was not working in an appropriate manner; consequently, that resulted in significant thickening of his heart muscle. Despite the abundance of traditional and alternative methods of CHF treatment, the cardiologist together with other physicians insisted on the open-heart surgery. Despite the fear of death and other anxieties, William J. agreed to the recommendation of the doctors. However, regardless of the fact that operation was successful, William felt very bad because he experienced continuous persistent shortness of breath. Therefore, his medications that were prescribed to him by his doctor did not reduce symptoms. For example, such common symptoms of CHF as fluid buildup and swelling led to unbearable discomfort because William could not communicate with people for a long period of time. Finally, in several weeks, William J. ended up in an emergency room because symptoms of his disease were worsening rapidly and considerably. William’s relatives decided to visit one of the best heart failure clinics in New York to meet professional cardiologists and get their recommendations for further treatment. When William J. together with his wife as a primary caregiver went to New York, Dr. Richard Morris after detailed examinations and analyses of tests administered him an effective treatment. In addition, Dr. Richard Morrison, who was the proponent of patient education, helped his patient understand his condition as well as its negative consequences on human health, and explained William that additional treatment and positive behavioral changes would positively impact his health and help ease the annoying symptoms. For example, this doctor informed William that he had to follow a healthy lifestyle and avoid negative habits and other stressors in order to prevent further heart damage. In other words, the doctor recommended William to follow a balanced and healthy diet because it would definitely lessen the consumption of sodium and excessive intake of calories. In addition, William should exercise on a regular basis, take medications as prescribed by the doctor, try to prevent health-threatening infections, and remember about positive atmosphere as well as emotional and psychological support. In general, Dr. Richard Morris is the proponent of the idea that education of patients with CHF can assist people in preventing hospital readmissions. It is important to note that William was incredibly excited to notice that his health condition improved significantly because he did not suffer from chest pain as well as did not experience difficulty breathing. Moreover, William’s relatives and close friends played a crucial role in managing and treating of William’s health condition because they provided him not only with material assistance but emotional support as well. William’s story proves that every person diagnosed with congestive heart failure has huge chances for effective treatment of this complex disease, rehabilitation, and healthy life. It is important to note that William understood that he, but not a doctor or his relatives, bears responsibility for his health, and consequently, he should follow effective preventive strategies with the primary purpose of managing signs and symptoms and slowing the rapid progression of the disease.

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PICO Questions

Question: What are the benefits and positive consequences of patient education with CHF on decreased hospital readmission and mortality rates in comparison to those patients who are not informed about the efficiency of patient education at the initial course of treatment?

Population: Patients with congestive heart failure (CHF).

Intervention: Patient education is one of the most effective methods that drastically decreases re-hospitalization or, in other words, hospital readmission rates.

Comparison of Interventions: Congestive heart failure patients who were not educated about the paramount importance of patient education at the initial stages of treatment.

Outcome: Reduced need in hospital readmission and decreased mortality rates among patients with congestive heart failure.

II Search for Evidence

Taking into consideration the selection, extraction, and synthesis of information, it is important to emphasize that numerous electronic databases were used with the purpose of finding accurate and valid sources of data. The first article by Islam et al. (2014) describes hospital readmission rates among older adults with congestive heart failure. This research study was derived from health services clinical information management program (Islam et al., 2013). The main keywords and combinations of keywords derived from the research study presented by Islam et al. are as follows: hospital readmission, congestive heart failure, and comparative cohort design (Islam et al., 2013). The second research study by Mudge at al. (2010) is a prospective longitudinal study that compares baseline and intervention cohorts. Queensland and Health Information Centre is the data source where the research study was obtained from. It should be stressed that the main keywords and key phrases of the second research study about the impact of quality improvement program on hospitalized patients with heart failure are as follows: congestive heart failure, disease management, readmission of patients, re-hospitalization, and finally, the quality of health care (Mudge et al., 2010). The research study by Bakal et al. (2014) is primarily purposed to review and evaluate the shortening gap between the repeat readmission of patients with HF. The research article was retrieved from several databases, including Discharge Abstract Database as well as Ambulatory Care Database (Bakal et al., 2014). In addition, the authors of the research study about the increasingly shortening gap distinguish a set of accurate key phrases, including heart failure readmission, re-hospitalization rates, multiple repeat hospitalizations, and many others (Bakal et al., 2014). The fourth research study by Rabbat et al. (2012) sheds light on the increased significance of readmission reduction programs for people diagnosed with congestive heart failure (Rabbat et al., 2012). In general, data collection was compiled on the basis of patient databases (Rabbat et al., 2012). The study conducted by Reynolds et al. (2015) presents information about the relation of hospital length of stay to readmission as well as mortality rates. In other words, the researchers aimed to prove that the length of hospital stays may either positively or negatively impact the increased readmission and mortality rates among patients with congestive heart failure (Reynolds et al., 2015). Taking into account the data collection instruments, it should be stated that the research study was obtained through health plan databases and clinical databases that are available in different hospital regions (Reynolds et al., 2015). Acute heart failure, subsequent readmission, mortality rates, progressive condition, and finally, heart failure should be identified as the main keywords as well as combinations of keywords used in the research study (Reynolds et al., 2015). Finally, the research study by Kaboli et al. (2012) describes and assesses the connection between the reduced hospital length of stay and readmission rates as well as mortality. In general, the data presented in the research study by Kaboli et al. (2012) was derived from different patient treatment files and administrative databases. In addition, large amounts of existing medical records were used to collect data (Kaboli et al., 2012). Accurate keywords and combinations of keywords presented in the research study are readmission rate, mortality, hospital length of stay (LOS), patient education, and others (Kaboli et al., 2012). The major limitation of the research study presented by Kaboli et al. (2012) is that it is based on Veterans Health Administration System as other types of admissions were unavailable (Kaboli et al., 2012). Therefore, having identified the databases searched as well as keywords and combinations of keywords used, it is possible to summarize that the number of articles and research studies used in the research project is equal to six. Despite the fact that the initial purpose of the research project was directly associated with congestive heart failure, this evidence-based practice research project reviewed and evaluated several aspect of this problem that are significant for the sphere of nursing. To begin with, two out of six research studies, those by Reynolds et al. (2015) and Kaboli et al. (2012), investigate close associations among the length of hospital stay, increased readmission, and mortality rates. The research studies presented by Mudge et al. (2010) and Rabbat et al. (2012) emphasize the positive impact of patient education, readmission reduction program, and quality improvement program on the decreased re-hospitalization and mortality rates. Finally, the articles presented by Bakal et al. (2014) and Islam et al. (2014) assess the main causes and reasons for the increased hospital readmissions among patients with congestive heart failure.

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III Literature Review

The research study Hospital Readmission among Older Adults with Congestive Heart Failure by Islam, O’Connell, and Lakhan (2013) aims to shed light on the factors directly linked to hospital readmission among older patients with CHF. According to the estimations of the researchers, the frequent likelihood of readmissions is predetermined by two major factors, including exacerbations of chronic illnesses and quality of hospital care (Islam et al., 2013). In addition, the researchers have revealed a range of risk factors associated with the increased readmissions of patients with CHF, including age, gender, ethnicity, duration of inpatient stay, and finally, socioeconomic status (Islam et al., 2013). Moreover, the researchers have found that the unstable financial situation, marital status, disability, social isolation, and several chronic diseases drastically increase the chances of hospital readmission of patients with CHF. On the basis of the comparative cohort design and other effective methods, the researchers determined the risk factors that impact patients’ readmission (Islam et al., 2013). It is important to note that out of 6,252 patients, the number of adults aged 65 years readmitted within 28 days was equal to 630. There appears to be strong evidence that male gender, financial constraints, comparatively long length of stay, several diagnoses, and finally, frequent transfers from different acute-care facilities and hospitals impact the readmission of patients for the period of 28 days (Islam et al., 2013). Finally, taking into consideration the gaps in the evidence, it is important to note that further work is necessary in order to investigate the length of stay as one of the risk factors because it still remains contestable (Islam et al., 2013). Therefore, demographic and clinical variables suggest that male gender and unstable financial situation are two major demographic characteristics that increase the likelihood of readmissions among patients aged over 65. On the contrary, age and the country of birth are not included to the list of significant factors that impact the increased readmission rates (Islam et al., 2013).

Another research study The Paradox of Readmission by Mudge et al. (2010) is primarily purposed to assess the influence of multifaceted programs connected with quality improvement in hospital utilization that lasts 12 months among patients with congestive heart failure. According to the estimations of the researchers, ACE inhibitors as well as beta-blockers, and finally, spironolactone are the main factors that contribute to the reduction of re-hospitalization and mortality rates (Mudge et al., 2010). A wide scope of factors, including professional care, balanced diet, moderate exercises, optimal pharmacological exercises, education and patients, and finally, effective self-management strategies, positively impacts patients with congestive heart failure (Mudge et al., 2010). The study by Mudge et al. suggests that a complex bundle of various interventions that encompasses education of people with CHF and integration among patients and health care providers considerably prolongs life expectancy, but at the same time, it increases hospital utilization (Mudge et al., 2010). It is important to note that provider-directed interventions include various support tools, especially education detailing, academic achievements, and regular feedback on the effectiveness of performance (Mudge et al., 2010). On the contrary, primary-directed interventions are based on evidence-based education of parents and patients’ diaries. According to the experiments conducted by Mudge et al. (2010), participants were accepted for further post-hospital interventions in case they did not suffer from cognitive or psychiatric health problems, their life expectancy exceeded the period of 6 months, and other predetermined requirements. The results of statistical data found that 107 patients out of 220 or, in other words, 49% of intervention patients with CHF were readmitted to hospitals and other health care facilities (Mudge et al., 2010). To begin with, the researchers came to conclusions that individuals with heart failure who agreed to receive a multidisciplinary intervention considerably improved the rates of 1-year post-hospital survival. Moreover, this research study reveals factors that impact the reduction of mortality rates within a particular intervention cohort (Mudge et al., 2010). The effectiveness of disease management programs depends on numerous factors, including better assessment of intervention components, targeting, and finally, intensity. Possible promises of disease management services and programs outside the so-called high-risk experimental population are considered to be the main gaps of the study that require further investigation (Mudge et al., 2010).

Bakal et al. (2014) in the research study about measuring the shortening gap between the repeat heart failure hospitalizations aimed to compare the repeat models of hospitalization. In other words, with participation of 40,667 individuals, the researchers planed to examine and evaluate the gap time model as well as multistate model (Bakal et al., 2014). On the basis of several databases, the amounts of hospitalizations, statistical analyses, and multivariable models, the researchers revealed that the gap time lessens between every successive hospitalization (Bakal et al., 2014). Having shed light on the main points of view presented in this research study, it is possible to infer that Bakal et al. have come to conclusions that one of the most significant goals of treatment evaluation is connected with widening the gap between hospitalizations (Bakal et al., 2014). The development of prediction scores for patients with heart failure requires further investigations.

Rabbat et al. (2012) who investigate the significance of heart failure readmission reduction programs for medical residents claim that congestive heart failure is one of the major causes of hospital readmissions that last approximately 30 days. The researchers successfully developed a STELR program in order to reduce the percentage of CHF readmissions (Rabbat et al., 2012). It is important to note that the STELR program included several components, especially peer-to-peer education and education of patients. The researchers insist on tremendous benefits of the STELR program for patients with CHF. For example, patient education encompasses education of people with CHF with participation of licensed nurses on the nature, consequences, and effective treatment of the disease that can prolong the life of patients and make it more qualitative (Rabbat et al., 2012). The results of the descriptive statistics claim that 65 patients between 49 and 99 years old were readmitted within 30 days after the initial discharge (Rabbat et al., 2012). Therefore, the finding suggests that involvement and active participation of patients with CHF in the STELR program has given the chance to quantify and compare changes in readmission rates and track patients with CHF (Rabbat et al., 2012). Consequently, implementation of the STELR program has contributed to improved physician documentation and effective management of medications, signs, symptoms, and treatment. In addition, the STELR program is characterized by numerous educational and economic benefits as it requires insignificant financial resources in comparison to other programs and services funded by the government. For this reason, Bakal et al. (2014) have made a conclusion that the STELR programs is worth implementing because of a number of advantages as it creates a platform for participants of the research team to serve as professional mentors for other residents (Bakal et al., 2014). Moreover, other huge benefits of STERL are closely intertwined with cost-effectiveness and accessibility of this program to all patients. The researchers insist on the great potential of this program and hope that it will contribute to patients’ education, outcomes, and health care savings (Bakal et al., 2014).

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Reynolds et al. (2015) have revealed that hospital length of stay is directly connected with subsequent readmission rates and all-cause mortality. According to the research results presented by the scholars, approximately 20 % of patients with HF are readmitted within the period of 30 days (Reynolds et al., 2015). In addition, it is believed that initial hospitalization of patients with heart failures increases the risks of poor outcomes and is one of the most obvious predictors for readmissions. The researchers aim to investigate whether the length of stay impacts hospital readmissions and mortality rates (Reynolds et al., 2015). The results of statistical data provide evidence that 21% of people with HF had readmission within 30 days and approximately 60% were readmitted into hospitals within the period that did not exceed 1 year (Reynolds et al., 2015). In general, the length of initial hospitalization does not impact the increased risks of possible readmissions and mortality among patients with HF. LOS that was shorter than 4 days was connected with lower rates of readmissions and mortality (Reynolds et al., 2015). Finally, despite the fact that readmission and mortality rates of patients with HF remain comparatively unchanged, Reynolds et al. recommend to promote self-management education of patients as it positively impacts the decreased readmission rates (Reynolds et al., 2015).

Kaboli et al. (2012) investigated the connections between the shortened hospital length of stay, increased mortality rates, and 30-day readmission. However, the researchers limited their research study to the system of Veterans Health Administration. Regardless of the fact that provision of high-quality care should be the priority of every health care facility, hospital length of stay may negatively impact the readmission rates among patients (Kaboli et al., 2012). There appears to be strong evidence that improvement of LOS drastically decreases the percentage of 30-day readmissions among veterans with various health problems (Kaboli et al., 2012). Because this research study has several limitations as it is based on a single health care system, further investigations should concentrate on the processes of care that would be generalized for all patients with different health disorders, especially CHF (Kaboli et al., 2012).

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VI Rating of Evidence

The role of hierarchy of evidence is tremendously important because this framework identifies and assesses the variety of research methods used in every research study and ranks them according to the validity of findings. Moreover, it should be emphasized that the strength of the proposed hierarchy of every research study gives the chance to acknowledge and evaluate the contribution of research studies to the sphere of nursing. In addition, the proposed hierarchy assesses the validity and accuracy of data processed and quality of each research study appraised. In general, none out of six analyzed research studies is grounded only on the ideas and opinions of unqualified individuals, case studies or reports, and other descriptive studies of poor methodological quality. To begin with, the research study by Islam et al. (2013) applies the cohort studies and multivariate analysis. The major strength of this research study is based on a large number of research methods applied (Islam et al., 2013). The hierarchy of evidence proves the high quality of the second research article by Mudge et al. (2010) because this research study is based on prospective longitudinal study that compares and contrasts baseline as well as intervention cohorts. The main strength of the research by Mudge et al. (2010) is based on the implementation of effective strategies that can reduce readmission rates among patients with heart failure. The research studies by Bakal et al. (2014) and Rabbat et al. (2012) may be ranked as excellent on the basis of hierarchy of evidence because they include systematic reviews and multi-centre studies. Therefore, the quality of both studies appraised is very high because both studies insist on implementation of effective hospital programs, including the STELR program, that can positively impact readmission rates (Bakal et al., 2014), (Rabbat et al., 2012). The research study presented by Reynolds et al. (2015) involves the retrospective cohort studies and observational studies, which is why this research study should be classified as feasible, accurate, and effective. Furthermore, large population sample and abundance of methods used are the major strengths of the research study by Reynolds and other researchers (Reynolds et al., 2015). Finally, the original research by Kaboli et al. (2012) occupies the highest level in regard to the hierarchy of evidence because sampling of this research study is based on valid and professional theory and literature. This study assesses relevance to different settings and presents comprehensible and clear analytical procedures (Kaboli et al., 2012).

V Summary of Evidence

Authors Year



Major Strengths Major Weaknesses Quality Score (out of 10)
Islam, T., O’Connell, B., Lakhan, P. 2012 · measures and assesses actual data connected with hospital readmission among older individuals with CHF;

· effectively uses several methods, including the comparative cohort design and logistic model of recession;

· a well-developed structure (subheadings, three tables);

· focus on patients aged over 65 years;

· difference among readmitted and non-readmitted patients with congestive heart failure;

· the use of valid data from professional sources (Islam et al., 2013).

· unclear definition of the term “readmission”;

· limited amount in interventions;

· insufficient amount of selected sample groups to distinguish more differences and variables (Islam et al., 2013).

Munge, A., Denaro, C., Scott, I., Bennett, C., Hickey, A., Jones, M. A. 2010 · includes accurate and comprehensible definitions of terms, especially congestive heart failure, readmission of patients, and disease management;

· is based on accurate and authentic information derived from journal articles and books;

· looks for empirical research as it reviews data by professionals in the field of interest;

· a well-developed structure of the research article, including background information, objectives, methodology, results, discussion section, and concise conclusion that summarizes the main points presented in the research paper;

· includes several interventions, especially provider-directed and patient-directed interventions;

· is based on up-to-date information as it measures and compares all-cause hospital readmissions among patients with HF over 12 months (Mudge et al., 2010).

· a non-randomized design of the study;

· limited sampling and insignificant amounts of participants (Mudge et al., 2010).

Bakal, J. A., Mcalister, F. A., Liu, W., Ezekowitz, J. A. 2014 · accurate presentation of information;

· detailed examination of two models, including the gap time model and multistate model;

· a population-based cohort that includes 40,667 patients;

· size and numerical basis of calculations;

· significantly large sample of population due to accessibility of the hearth care programs in Alberta, Canada;

· the use of several methods and accurate statistical analyses to obtain the evidence;

· well-developed and precise presentation of information that encompasses four tables and four figures that show timeline of hospitalization and baseline cohort demographics (Bakal et al., 2014);

· unclear definition of the term “heart failure”;

· inaccurate record of co-morbidity statistics;

· limitations of database application (Bakal et al., 2014).

Rabbat, J., Bashari, D. R., Khillan, R., Rai, M., Villamil, J., Pearson, J. M., Saxena, A. 2011 · accurate definition of terms, including congestive heart failure, hospital readmission, and system-based practice;

· development of the STELR program that contributes to improved patient management and patient education;

· effective cooperation and interaction with sample population;

· accurate synthesis of information;

· effective delivery and structure of information, including background information, methods, results, and precise conclusions (Rabbat et al., 2012).

· limited sample of information;

· needs additional collaborative evidence;

· lacks visual evidence (as the research study includes only one figure that shows the percentage of patients with congestive heart failure readmitted within the period of 30 days) (Rabbat et al., 2012).

Reynolds, K., Butler, M. G., Kimes, T. M., Rosales, A. G., Cjan, W., Nichols, G. A. 2015 · enormous contribution of the researchers to the field of study as they developed several effective strategies that nurses should follow in order to reduce quick progression of the disease, severity of congestive heart failure, and mortality rates among patients with CHF;

· a well-developed structure of the research study, including graphs, tables, and figures;

· valid and accurate data from professional sources;

· evaluation of three outcomes of the research study (Reynolds et al., 2015).

· large sample of population (19,927 patients hospitalized with congestive heart failure) from different ethnical, cultural, and geographical backgrounds;

· accurate synthesis of information;

· measures readmission rates among patients with CHR failure from 2008 to 2011 from 3 different Kaiser Permanente regions;

· Kaiser Permanente system is not adapted to American healthcare system;

· relies on data that is available in electronic medical records, and consequently, might not have included all potentially confounding variables (Reynolds et al., 2015).

Kaboli, P. J., Jorge, T., Hockenberry, J., Glasgow, J. M., Johnson, S. R., Rosenthal, G. E., Jones, M. P., Vaughal-Sarrazin, M. 2012 · the use of large sample of population;

· a well-developed structure of the research study;

· observational study from 1997 to 2010;

· effective presentation of information as tables, graphs, and figures are included;

· reliability of research results;

· clear and accurate synthesis of information;

· several appendices that provide accurate data (Kaboli et al., 2012).

· lacks clear and precise conclusion;

· inability to make a difference between preventable readmissions and other types of readmissions;

· generalizations of the results of the study;

· no measure of preventability of readmissions (Kaboli et al., 2012).


VI Recommendations for Treatment

Having identified and assessed the strengths of evidence and clinical judgments, including the implications for further evidence-based practice and professional team collaboration, it is possible to make recommendations for reduced hospital readmission rates among patients with congestive heart failure. Islam et al. (2013) who investigate hospital readmission rates among adult individuals with CHF insist on the recommendation to develop a high-quality “readmission risk-screening tool” for medical staff that would assist in identifying risky patients before being discharged from hospitals or other healthcare facilities (Islam et al., 2013). Mudge at al. (2010) recommend creating and implementing a disease management service within hospital settings in order to reduce the amounts of readmissions in a cost-effective manner (Mudge et al., 2010). Bakal and his colleagues (2014), who have shed light on a shortening gap between re-hospitalizations of patients with HF, have come to conclusions that the increased quality of health care establishments and professionalism of the nursing staff will drastically decrease the amount of readmissions (Bakal et al., 2014). Rabbat et al. (2012) recommend implementing the STERL program because it is cost-effective and positively impacts the health and well-being of patients with heart failure (Rabbat et al., 2012). The researchers insist on the idea that application of the STERL program within large hospital settings and a significantly larger population sample will result in favorable outcomes. Taking into account the recommendations presented by Reynolds et al. (2015), it should be stressed that the authors have suggested a wide scope of strategies that can help nurses reduce the severity of heart failure and minimize the mortality rates within the context and quality of hospital length of stay (Reynolds et al., 2015). Finally, the research study by Kaboli et al. (2012) concerning the connection between the hospital length of stay and readmission rates includes recommendations that professional work of the nursing staff and improved conditions of health care facilities can contribute to the decreased readmission and mortality rates (Kaboli et al., 2012).

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