Evidence-Based Plan for Heart Failure Clinic: Discharge Education

This report details an evidence-based plan for a nurse-run outpatient heart failure clinic, developed to address high readmission rates within 30 days of discharge. The plan emphasizes the implementation of the IDEAL Discharge Planning strategy, which includes involving families, discussing key areas for home care, providing education on the patient's condition and medications, assessing understanding, and listening to patient concerns. The report highlights the importance of consistent discharge education, compliance with evidence-based practice protocols, and the integration of cardiologists and other healthcare team members. The goal is to improve the quality of care, reduce readmission rates, and enhance patient outcomes for individuals suffering from heart failure. The report also discusses the importance of educating the patients and their families about the disease and treatment plans.

Running head: EVIDENCE-BASED PLAN FOR HEALTHCARE
Develop an Evidence-Based Plan for Health Care Delivery
Student Name
University Name
Author Note

1
NURSING
Introduction
Patients suffer from heart failure because their heart muscles are unable to pump
enough blood to the body as they normally should. This can happen due to a number of
underlying diseases like coronary heart disease or arteriosclerosis (Okuyama et al., 2015).
The inefficiency to pump blood can cause the body to not get enough of oxygenated blood for
the cells to function properly. Hospitals have acute care settings where patients suffering
from these kinds of illnesses are admitted for treatment (Kelkar et al., 2016). Nurses, during
their education, are provided with special education to help the patients get quality care. The
quality of the care provided by the specialist nurses deployed in acute care has shown to
improve the treatment of the patient and reducing the number of readmissions and mortality
rates. The main objective of the nurses is to take care of the well-being of the patient while
giving them the necessary treatment (Dreyer et al., 2016). The evidence-based discharge
education plan is being discussed that is implemented by nurses to improve discharge day for
patients.
IDEAL Discharge Planning Strategy
Transfer of information of the patient to the clinician regarding the discharge from
hospital prevents adverse events and reduces readmissions. Involvement of families of the
patient in the planning process makes this effective and safe. There is step-by-step guidance
followed by nurses implementing the IDEAL Discharge Planning (Weiss et al., 2015).
The I in IDEAL stands for Include. It means including the families of the patient in
the planning process of discharge ("Care Transitions from Hospital to Home: IDEAL
Discharge Planning Implementation Handbook", 2019). The members of the family who will
be present with the patient after they have been discharged from the hospital should be
included in the meetings for them to understand the type of care the patient needs and they

2
NURSING
have to provide. The initiation of the planning process should be starting since the first day of
the admission in the hospital. It should be well understood by the patient as well as the family
members.
The D in IDEAL stands for discussing. This step revolves around the discussion of
the key areas that will prevent problems at home. The environment at home of the patient
should be informed to the clinician to help make a patient-centered plan ("Care Transitions
from Hospital to Home: IDEAL Discharge Planning Implementation Handbook", 2019).
Information regarding the patient’s eating habits, allergies to certain medications and the
activities they are prohibited from doing must be mentioned to the nursing professional for a
proactive discharge plan for the patient. The nurse will be taking up the duty to make the
patient and their family understand the utility associated with the medications that have been
prescribed to the patient. The apparent side-effects and the number of medicines to be taken
must be clearly specified to the family who will be in charge of administrating the
medications to the patient. Explanation of the test results must be provided to the family as
well as the patient for better understanding of the illness that is being contracted by the
patient. Follow-up appointments with the physician specialising in cardiology must be made
with clear specification of the importance of it. This will help the family understand the
significance of the follow-up and reduce the risk of readmission in cases of heart failure.
The E in IDEAL stands for educating. This includes the providing of education to the
family as well as the patient about the heart condition and the risk that is associated with this
condition ("Care Transitions from Hospital to Home: IDEAL Discharge Planning
Implementation Handbook", 2019). The reasons why this condition is prevalent in the patient
must be corroborated with the lifestyle that is associated with the patient. The patient should
be provided every day with information about the medications that they have been prescribed
for the day. This will help the patient in understanding their condition and the degree of

3
NURSING
improvement in their condition. The family of the patient should be encouraged to take part
in care providing practices to support the caregiving procedure at home. Learning them when
the nursing professional is present will help the family in implementing the techniques faster
and in a better way, thus reducing the readmission rates of the patient.
The A in IDEAL stands for assessment. Proper assessment from the patient and the
family must be regularly taken to improve the quality of information that has been transferred
by you ("Care Transitions from Hospital to Home: IDEAL Discharge Planning
Implementation Handbook", 2019). Providing information in small amounts will help the
patient and their family to grasp the information more clearly and incorporate into the
caregiving procedure when they have been discharged from the hospital. Regular asking the
family to repeat the pieces of information that have been shared on that day will help the
nursing professional understand whether they have given out the information clearly or not.
The L in IDEAL stands for listening. This involves listening to the concerns that are
associated with the family members of the patient ("Care Transitions from Hospital to Home:
IDEAL Discharge Planning Implementation Handbook", 2019). There are booklets and
checklists available in hospitals that must be given to the members accompanying the patient
to make it comfortable for the family as well as the patient about the discharge.
It has been observed in around 25 per cent of the cases of patients associated with
heart failure to experience an adverse event in 2 weeks of discharge (Murtaugh et al., 2017).
This can take place due to the onset of hospital-acquired infections or complications in the
caregiving procedure. Readmission rates have been increasing in the hospitals which can be
decreased significantly by the incorporation of the IDEAL Discharge Planning Process
Dallmann, Wilks & Mattke, 2019). Patients and their family members have been observed to
not take the discharge planning process seriously. It has been a common convention that once

4
NURSING
the patient has been discharged from the hospital after the treatment, there is a low possibility
of relapse. Necessary education is to be provided by the nurse to the members to make it clear
the importance of treatment and the side-effects that are associated with the condition. The
hospital team including leaders, nurses, physicians and other management staff with patient
representatives should be present when the meeting is being conducted (Shanafelt &
Noseworthy, 2017). Role-plays should be organized to help other clinician staffs to
understand how the process of discharge feels to the family and the patient. It is necessary for
the nurse to assess the primary areas where IDEAL should be incorporated to reduce the risk
of readmission in patients suffering from heart failure.
Conclusion
In concluding remarks, it can be understood that the implementation of the IDEAL
Discharge Plan Strategy can help in the reduction of the readmission rates of patients who
have been suffering from heart failure condition. This condition has been termed risky, as
many cases of readmission have been observed. This can be significantly reduced by the
incorporation of the IDEAL strategy. The patient and their family members should be
provided with the necessary information of the treatment and the precautionary measures that
must be undertaken by them to take care of the patient.

5
NURSING
References
Care Transitions from Hospital to Home: IDEAL Discharge Planning Implementation
Handbook. (2019). Retrieved 8 August 2019, from
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/
engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
Dallmann, A. C., Wilks, A., & Mattke, S. (2019). Impact of Event Severity on Hospital
Rankings Based on Heart Failure Readmission Rates. Population health
management, 22(3), 243-247.
Dreyer, P., Angel, S., Langhorn, L., Pedersen, B. B., & Aadal, L. (2016). Nursing roles and
functions in the acute and subacute rehabilitation of patients with stroke: going all in
for the patient. Journal of neuroscience nursing, 48(2), 108-115.
Kelkar, A. A., Spertus, J., Pang, P., Pierson, R. F., Cody, R. J., Pina, I. L., ... & Butler, J.
(2016). Utility of patient-reported outcome instruments in heart failure. JACC: Heart
Failure, 4(3), 165-175.
Murtaugh, C. M., Deb, P., Zhu, C., Peng, T. R., Barrón, Y., Shah, S., ... & Siu, A. L. (2017).
Reducing readmissions among heart failure patients discharged to home health care:
Effectiveness of early and intensive nursing services and early physician follow‐
up. Health services research, 52(4), 1445-1472.
Okuyama, H., Langsjoen, P. H., Hamazaki, T., Ogushi, Y., Hama, R., Kobayashi, T., &
Uchino, H. (2015). Statins stimulate atherosclerosis and heart failure:
pharmacological mechanisms. Expert review of clinical pharmacology, 8(2), 189-199.

6
NURSING
Shanafelt, T. D., & Noseworthy, J. H. (2017, January). Executive leadership and physician
well-being: nine organizational strategies to promote engagement and reduce burnout.
In Mayo Clinic Proceedings (Vol. 92, No. 1, pp. 129-146). Elsevier.
Weiss, M. E., Bobay, K. L., Bahr, S. J., Costa, L., Hughes, R. G., & Holland, D. E. (2015). A
model for hospital discharge preparation: From case management to care
transition. Journal of Nursing Administration, 45(12), 606-614.