More than five million Americans have heart failure, making it one of the leading causes of hospitalization. Five-hundred and fifty thousand new cases are diagnosed each year in United States. Experts estimate that by 2030, more than eight million Americans will have heart failure. That’s one out of every 33 people.
Heart failure also accounts for the highest 30-day readmission rate of any diagnosis. There are more than one million hospitalizations each year in the United States. A new program at the University of Vermont Medical Center is reducing that rate, seeing a 14% reduction in its first year.
Robert Hamble, BSN, CHFN, RN, a heart failure nurse clinician at UVM Medical Center, talks about how this new patient education program is changing – and prolonging – the lives of patients.
What is heart failure?
Hamble: Heart failure may happen when we don’t manage other health issues in our lives. What that means is that if my mom and dad have high cholesterol, I may have high cholesterol, and if I don’t manage that high cholesterol it could lead to me having a heart attack, which could lead me to having heart failure.
Heart failure is caused by something else. It could be due you not managing your high blood pressure, which causes your heart to work harder. Or, you have a heart attack, which causes muscle to die, which causes your heart to work harder. We often explain to patients that heart failure doesn’t mean that you’re not going be with us tomorrow, it just means that your heart is failing to do its job correctly, like a car. A car has six cylinders and, unfortunately, in heart failure you’re only firing on four.
How do you know if you have heart failure?
Hamble: The symptoms of heart failure are subtle. What we know is patients often have symptoms for two to three weeks before they realize that something is wrong.
A common symptom is rapid weight gain. If a person gains three pounds in a day or five pounds in a week, it’s a sign that they’re retaining fluid and that their heart may be having a hard time keeping up. Their ankles may swell; their pants may get tighter. They’re short of breath. It may start off with walking from the house to the car and getting winded, to the point that when you reach the kitchen table you are gasping for air.
What diagnostic testing is done?
Hamble: If someone is not feeling well, a doctor may prescribe an echocardiogram or an ultrasound of the heart. The physician will look at the structure of all four chambers in your heart. A doctor will analyze the results and compare to what is normal to see if your heart has become weaker or stiffer.
What is a readmission rate?
Hamble; We assess ourselves against a statistic called a 30-day readmission rate. It’s how the federal government evaluates if we’re doing a good job as a healthcare provider.
If a patient is admitted for heart failure, our goal is to make sure that they don’t get readmitted in 30 days. That means we’re doing our job to ensure that they’re getting the right treatments, the right transition of care, and following a program that will benefit them in the long run and prolong their life.
Why is the readmission rate so high for heart failure patients?
Hamble: Heart failure is comparable to diabetes. In the same way that people with diabetes check their finger sticks daily and watch what they’re eating, patients with heart failure must constantly monitor themselves. They watch their salt intake, fluid intake, take medications, and monitor for symptoms. The better a patient manages heart failure, the less likely they’re going to be readmitted to the hospital.
I always say to my patients, “We’re not going to cure heart failure. My job is to give you the information so that you can live long enough to see your daughter walk down the aisle, watch your kids graduate, play with your grandkids.” And that’s the beauty of it. As long as patients do what they need to do and follow this program, they’re going to live a healthy life.
That said, it’s hard and complicated. A patient may not realize that a slice of American cheese has 350 milligrams of salt, or that a hot dog has more than 900 milligrams of salt. We call this “secret” or “hidden salt,” and it gets people in trouble. A patient may have a doctor’s appointment that day and think: “Well, I won’t take my water pill today because I have to go to see my doctor.” That gets them onto that slippery slope, which may cause a readmission.
Tell us about the patient education program that you developed?
Hamble: We created a program where we spend a minimum of one hour with every patient who has a diagnosis of heart failure. We use skills like motivational interviewing to help patients understand how to make lifestyle and other health behavior changes. We focus on four key areas of heart failure management: 1) Weigh yourself daily, 2) Know the symptoms, 3) Fluid restriction, and 4) Salt restriction.
We have an amazing team that includes a dietary team that meets with all of our patients to sit down and explore what they eat, so they can know what they can eat when they go to Olive Garden, or to 99. We have a pharmacy group that meets with them to complete medication reconciliation. We have a great transition of care team that works outside of the hospital with our patients. And our doctors are great in providing our patients with the right treatments at the right time.
Our nurses play a huge role of continuing to re-emphasize the key points, and work with patients on relationships. Nurses are the ones sitting down with patients and asking questions like: “How is it going to look for you in a couple of months?”, “What are your thoughts about this salt restriction?”
What do patients struggle with the most?
Hamble: There are two areas where patients struggle the most. First, being told they have heart failure because that word is a pretty scary word, and I understand that. Even though I do this everyday, telling somebody they have heart failure could be devastating, and my job is to, with the help of others, break that down into little pieces so they can process it, understand that this is a serious issue, but that it’s something you can deal with, and if we do it the right way, you can live a completely normal life.
The other thing is salt intake. I’m a guy who likes bacon and it’s hard to change people’s diets. To say, “You have to give up salt,” even if they know that it’s something that could hurt their heart, is a tough conversation. We try to focus on the idea that it’s not about getting rid of salt, it’s about how you manage your intake.
What is the feedback from patients?
Hamble: The feedback we hear from patients is that this is an opportunity for them to explore what heart failure is. We give them all the resources at their fingertips to start asking questions. We bring the family in, and the beauty is this has started to grow roots. So now we’ve reached out to our primary care groups. They’re aware of what we’re teaching. We’ve met with our visiting nursing groups, so they understand how we teach so that when our patients go out into the community, they continue to hear the same messages. So, it’s not being reinvented, it’s just being supported.
How do patients interact with the program outside of the hospital?
Hamble: We have a couple of programs, including our cardiology outpatient clinic and cardiac rehab, which a lot of our heart failure patients can access. Throughout these programs providers reemphasize diet change, the importance of exercise, and signs and symptoms to look for.
Our pharmacy group follows up with our patients a few days after a patient is discharged to make sure that they’ve picked up their medications and that they’re taking the right medications.
Then, we do another follow-up call a couple of weeks later to make sure that they’re not starting to slip, and that they understand what they need to do. So, they’re continuously receiving support.
What successes have you seen so far?
Hamble: What we’re doing is a truly forward-thinking approach to patient education – and the results are showing. Our patients are engaged. Our readmission rates for heart failure are lower than the national average.
Any personal success stories to share?
Hamble: I had an amazing experience where a patient connected with me in public. He pulled me aside and we had a meaningful moment during which he expressed how the program has affected his life. He lost 60 pounds, he’s more engaged with his doctors, and because of this the doctors have seen improvement in his heart and they’ve actually started to dial back some of his medications. That was a meaningful for me because here was a patient who bought into the program, thought about it, implemented it into his lifestyle, and then he saw big benefits.