Evidence base-practice approach to prevention of congestive heart failure readmissions


Unit 1: — Introduction of Population


Unit 11:- Health Promotion

Identification of health promotion needs

Description of interventions

Unit 111:- Evaluation

Identification of measuring tools

Evidence base-practice approach to prevention of

congestive heart failure readmissions


Unit 1:- Introducing the population

The population identified for this workspace participation project are people over 60 years old affected by congestive cardiac failure residing within the Miami geographic location. From 2011 census reports the average population of Miami Florida is 400, 509; 49% males and 51% females. There is a median age of 38.8 years and life expectancy is 81.3 years with men falling behind at 75.2 and women 82.9 strong. Miami has the highest over 65 age group population within United States of America. The median income is $28,999 (US population census, 2011).

Besides, Miami, Florida is a multi-ethnic society. There are 65% whites inclusive of Hispanics and 35% African American/Caribbean people. As such, the cultural diversity is evident in food, entertainment, craft, architecture and life styles. For example, the Haitian American segment of the population believes in alternative medicine and to some extent the Caribbean populations turn towards natural cures for many illnesses such as hypertension and diabetes. However, the Caucasian portion of whites adhere to scientific medicine guidelines and Hispanics follow a mixture of alternative as well as scientific medicine based on their cultural preferences (US Population Census, 2012).

Specific growth and development characteristics of people over 60 years old can be described depending on their culture and sex. Women tend to live longer and remain healthier. Remarkably, from a physical perspective this age appears after menopause and fertility adjustments. There may also be changes in body weight and some bone alterations can be detected due to reduction in hormone levels. As such, the tendency to develop arthritis becomes obvious.

The psychosocial impact of women aging tends to manifest as changes in mood and either enhanced or reduced self-esteem depending on the social environment involvement. Usually, due to body mass changes women tend to feel less attractive. Also, when skin loses its adipose tissue and becomes wrinkled and saggy these may create some self-esteem issues that influence how women accept the aging process.

Men do not experience early aging changes in reproductive organs as women. Consequently, except for when impotence occurs. They have a greater self-esteem and sometimes engaged in sexual affairs with younger women who have not begun aging. These are the major differences between genders in growth and development stages over the age 60 age group.

However, according to Arend Mosterd and Arno W Hoes (2007) studies in the symptoms of heart failure among people over 60 years old can be described from the perspective of a syndrome. These symptoms/signs become evident as cardiac dysfunction, which can greatly reduce the life expectancy of any human (Mosterd & Hoes, 2007).

Subsequently, the European Society of Cardiology offer guidelines in establishing a diagnosis based on symptoms and signs which appear as a syndrome.


Symptoms                                                                          Signs

Dyspnea (on exertion, nocturnal) Edema, ascites
Reduced exercise tolerance Elevated jugular venous pressure
Fatigue, lethargy Crepitation or wheeze
Orthopnea Tachycardia
Nocturnal cough Third heart sound, murmurs
Wheeze Hepatomegaly
Anorexia Displaced apex beat
Confusion/delirium (elderly Cachexia and muscle wasting


(Mosterd & Hoes, 2007).

There are marked compensatory mechanisms, which include echocardiography; activation of the neurohormonal system, increase in natriuretic peptide concentrations especially, B type natriuretic peptide (Mosterd & Hoes, 2007).

Rich, Vinson, Sperry, Shah, Spinner, Chung and Davila-Roman (1993) examined prevention of readmission in elderly patients with congestive heart failure through a prospective, randomized pilot study. The researchers concluded that ‘a comprehensive, multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with congestive heart failure may lead to a reduction in readmissions and hospital days, particularly in patients at moderate risk for early rehospitalization’ (Rich, 1993).

In this workspace unit the targeted population are elderly over age 65 within Miami Florida geographic location diagnosed with congestive cardiac failure. The focus of this health promotion intervention is to prevent readmission through education and encouraging adherence to self-management techniques. Research has shown where readmissions may be a consequence of incomplete treatment or poor care of the underlying problem, which reflects inadequate coordination of healthcare services after admission when patients are placed in the community (Goldfield, 2008)


Goldfield, N. McCullough, E. Hughes, J. Beth Eastman, A. Rawlins, L.,& Richard, A.(2008).

Identifying Potentially Preventable Readmissions. Health Care Financing Review, 20(1),


Mosterd,M., & Hoes, A.( 2007). Clinical epidemiology of heart failure. Heart, 93(9), 1137-1146

Rich, M.Vinson, M. Sperry,J. Shah, A.Spinner, L.Chung,K  Davila-Roman, V. (1993).

Prevention of readmission in elderly patients with congestive heart failure: results of a

prospective, randomized pilot study. J Gen Intern Med, 8(11), 585-90

US population census ( 2012). US and World Clock Census Bureau. Retrieved 21st   January,

2013  from


Evidence base-practice approach to prevention of

congestive heart failure readmissions

Unit 11:- Health Promotion

Theories of health promotion encompass a series of assumptions. First, health promotion begins with families and then moves towards communities. The health belief model, however, undergirds all these theoretical assumptions. This model embraces the concept that health behavior to a great extent is influenced by personal belief systems; paradigms or perceptions. These perceptions as in case of the diversity of Miami population affect adherence to medical intervention as well as acceptance of disease effects on the body (Health Belief Model, 2012)

Four perceptions vital to this model are perceived seriousness; perceived susceptibility; perceived benefits and perceived barriers. Interpretation of seriousness depends on how the disease has been communicated to the individual or how it compromises the life style of the person being affected. Perceived susceptibility pertains an awareness of likelihood to contract a disease if certain measures are not taken as in the case of vaccinations (Health Belief Model, 2012)

Subsequently, perceived benefits along with the awareness of susceptibility are two of the strongest forces in health promotion compliance. It is attached to the belief that conformity will either eliminate the disease altogether, prevent development if it has not occurred or relief disturbing symptoms. Importantly, if benefits cannot be perceived logically this then becomes a perceived barrier to adherence. It is highly likely that people will readily respond to change if they can perceive personal benefits. Alternatively, if it requires working on themselves or making drastic adjustments to life styles it is difficult to be accomplished (Health Belief Model, 2012)

Identification of health promotion needs

According to Goldfield (2007) and counterparts many readmissions of congestive cardiac patients are preventable. The assumption is that they may be a consequence of incomplete treatment or poor care of the underlying problem, which reflects inadequate coordination of healthcare services after admission when patients are placed in the community (Goldfield, 2008).

As such, health promotion to prevent re-admission should be aimed at evaluating the quality of care extended to Miami congestive cardiac patient population during hospitalization. Precisely, it is to detect inaccurate assessment, misdiagnoses and mismanagement of the condition primarily. This is pre-requisite for designing a preventative education program when patients are discharged to function at home and in the community.

Specifically, the need is to enhance hospitalization and educate patients regarding self-care. Self-care would involve taking medication as prescribed, avoid strenuous activities that would aggravate heart; eat foods low in fats and cholesterol, avoid stress and engage in liberal physical exercises. When incorporating theories of health promotion in identifying these needs it must be understood that this target group must perceive the seriousness, susceptibility, benefits to overcome barriers (Health Belief Model, 2012).


Description of interventions

The first intervention relates to interdisciplinary collaboration in preventing readmissions of congestive cardiac patients of the over 60 year old in Miami, geographic location. At the primary care level it would mean aligning goals with physicians for accurate evaluations during visits so that there would be consistency in recording patient’s data in cases of admissions. There must be enough information within the clinical information system to accurately align symptoms and signs in arriving at an accurate nursing diagnosis, which determines a favorable outcome.

Interdisciplinary collaboration today in nursing has evolved as the foundation for translating evidence into practice. Nancy Fugate Woods and Diane L. Magyary (2010) contend that with all the evidence informing scientific interventions within the discipline no single person or discipline can alone translate these evidences into practice. It does not only take teamwork, but collaborating skills to achieve outcomes (Woods & Magyary, 2010).

Therefore, preventing readmission of elderly congestive cardiac failure patients would mean implementing strategies at primary, secondary and tertiary levels of health promotion. It would necessitate following established protocols and guidelines based on evidence from research findings. According to the clinical practice guidelines established for managing heart failure there is a distinct referral and evaluation system (Medical Associates, 2012).

It requires that the primary care physicians, mid-level providers or cardiologists refer patients after diagnosis to a Heart Failure Program. These programs are expected to follow up on diagnostic evaluations; establish the etiology of heart failure and conduct the necessary enrolment if systolic dysfunction is the dominant cause (Medical Associates, 2012).  It is believed that if this protocol is observed there can be fewer readmissions within the Miami geographic location.

At the secondary level health promotion intervention guidelines point towards specific medical management. They include prescribing and administering of loop diuretics; ACE inhibitors; beta blockers; monitoring reactions to and adjusting ACE dosages; eliminating drugs which produce serious side effects, lipid management, diabetes management and any other underlying predisposing factor of Congestive Cardiac failure (Medical Associates, 2012).

Residents over 60 age group within the Miami location take full advantage of Medicaid, Medicare and private insurances. A major portion of this population is uninsured. Therefore, length of hospitalization and frequency of readmissions to a great extent depends upon the insurance coverage available. The difficulty lies in Miami residents being multiethnic whereby many do not adhere to medication guidelines. Once side effects appear the tendency is to discontinue the drug after discharge. This poses a serious problem that influences readmissions.

Therefore, after discharge education programs must be designed to prevent readmissions leading to the tertiary level. They must be designed for interaction whereby residents can discuss their treatment and alternatives offered once symptoms and signs can be abated or controlled. Rich (1993) and counterparts’ study provided evidence for tertiary level intervention.

The researchers examined 98 patients over 70 years old who were admitted to a tertiary level institution after being diagnosed with congestive cardiac failure. A program was instituted for 90 days. It entailed intensive teaching by a geriatric cardiac nurse and a detailed review of medications by a geriatric cardiologist. The aim of this intervention was to identify specific ways in which patients can comply with medication administration (Rich, 1993)

Ultimately, side effects can be reduced, ‘early consultation with social services to facilitate discharge planning can be enhanced, dietary teaching by a hospital dietician could begin, and close follow-up after discharge by home care and the study team be organized’(Rich, 1993). These researchers supported the interdisciplinary collaborative approach advocated in this intervention.


Health Belief Model (2012). Theoretical Constructs. Jones and Bartllet.

Goldfield, N. McCullough, E. Hughes, J. Beth Eastman, A. Rawlins, L.,& Richard, A.(2008).

Identifying Potentially Preventable Readmissions. Health Care Financing Review 20(1),


Medical Associates (2012). Clinical Practice Guideline for Heart Failure. Medical Associates

clinic and health plans. H:\QI\QI\Practice

Guidelines\2012\COMPLETED\Congestive_Heart_Failure.doc. Me

Rich, M.Vinson, M. Sperry,J. Shah, A.Spinner, L.Chung,K  Davila-Roman, V. (1993).

Prevention of readmission in elderly patients with congestive heart failure: results of a

prospective, randomized pilot study. J Gen Intern Med, 8(11), 585-90

Woods, F., & Magyary, D. (2010). Translational Research: Why Nursing’s

Interdisciplinary Collaboration Is Essential. Research and Theory for Nursing

Practice: An International Journal, 24(1), 9-20


Evidence base-practice approach to prevention of

congestive heart failure readmissions

Unit 111: Evaluation

Rootman (2001) quoting Patton ( 1997) emphasized that there are six principles implicit in the framework for evaluating health promotion initiatives, interventions or programs. These include making sure the most appropriate evaluation methods are applied. Second, employing consistent health promotion principles when executing the process; third, focusing on collective as well as individual accountability; fourth, being flexible in application of theoretical assumptions; fifth evaluating all stages of the process and sixth be articulate enough to apply all levels of evaluation to the project (Rootman, 2001).

Consequently, there are eight important implementation steps embodied in principles outlined in the previous paragraph. These embrace designing an evaluation team; identifying pertinent issues to be evaluated in the project; designing the process through which information is to be retrieved. Fourthly, collect data based on a previously agreed plan; fifthly, analyze data retrieved, sixthly, make recommendations to stakeholders; seventh, disseminate information to the funding agencies and finally plan remedial interventions based on data collected (Rootman, 2001). It is in acknowledgement of these prerequisites that an evaluation of the foregoing project will be undertaken.

Identification of measuring tools

The Innovation center for community and youth development offered guidelines in evaluating interventions. It was advised that the tools applied depend greatly on the outcome which needs to be measured (Innovation Center, 2005). In this case the variables to be measured are response to education at three levels of intervention; the extent to which interdisciplinary collaboration was successful and whether re-admission rates were reduced

Evaluation Plan

Criteria Tool Desired outcome
Education Survey – Administer questionnaires after each session. Improvement in medication compliance; keeping doctors’ appointments and high risk behaviors such as alcohol consumption/inadequate diet.
Interdisciplinary collaboration Interview-

Ascertain how stakeholders adapted towards transference of evidence into practice in the effort to reducing re-admission prevalence.

Improved patient compliance to care guidelines at all levels of the intervention.
Re-admission rates Data retrieval-

Conduct an electronic document analysis after 3 months to determine whether readmission rates have been reduced.

Significant reduction in admission rates



Program evaluations are necessary for some of the following reasons:-

  • They help collect evidence on the effectiveness/impact of a program.
  • It holds executors accountable to stakeholders: funders, clients, volunteers, staff, or


  • It helps in identifying ways to improve a program:
  • It re-assesses needs of target population
  • It identifies strategies for improving the usefulness of program materials

(Health Communication Unit, 2007)


Health Communication Unit (2007). Evaluating Health Promotion Programs. Department

of Public Health Sciences, University of Toronto

Innovation Center for Community and Youth Development (2005). Developing and

         implementing evaluation Plan. Reflect and Improve Tool Kit

Rootman, I. (2001). A Framework for health promotion evaluation. World Health



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