The study was conducted at St. Luke’s Medical Center in Houston Texas.

1. Follow-up Diet Education for Congestive Heart Failure and Effects on Readmission Rates NehaBhakta, BS,Cyndra Banta, MS, RDN, LD, Kathryn Chiles, MS, RD, CNSC ARAMARK Distance Learning Dietetic Internship Program, Houston, TX METHODOLOGY CONCLUSION ABSTRACT • The study was conducted at St. Luke’s Medical Center in Houston Texas. • All patients will be 18 years of age or older and provide consent to participate in the study. • Patients who are discharged to long-term care facilities, skilled nursing facilities, non- English speaking or have a history of cognitive disorder such as dementia were excluded from the study. • A randomized controlled study design was used to identify congestive heart failure patients. • Diet education was provided to patients admitted with CHF or had a past medical history of CHF. • The control group received diet education (low sodium) during their hospital stay. • The intervention group received low sodium diet education during their hospital stay as well as a follow-up discharge call approximately two weeks post discharge from St. Luke’s Medical Center. • A questionnaire was also used to determine patient’s understanding and compliance after discharge. • Study included retrospective records review. • Electronic files or medical records were obtained through the EPIC medical records database and CBORD food service database. • Patients in this study were not at any physical, psychological, or social risks. • The follow-up calls were made approximately two weeks post discharge. • On the 30th day post discharge, a report through EPIC determined if any of the study patients were readmitted with congestive heart failure. • IRB approval was not needed for this project. • The predicted outcome for this study was that fewer patients from the intervention group will be readmitted to the hospital within 30 days post discharge from initial hospital visit. • Although the data gathered in this study was not reflective in that the intervention decreased readmission rates, it was helpful in determining what is needed for future research. • With the data gathered from the questionnaire: • I t is evident that patients need follow up diet education for conditions such as CHF. • Perhaps they are not able to recall all information presented to them at the in-patient diet education consultation due to their condition or state of health at that time. • Also, as healthcare professionals, we need realistic learning components, as they are not able to recall components such as “how many milligrams”. • Possibly if the information were presented in teaspoons or other units of measurements, the patients would be able to recall the information and apply it in their daily lives. • Perhaps patients with CHF would highly benefit from outpatient diet educations sessions once they have been discharged from the acute care setting. • Out patient settings are known to be a better learning environment and time can be adjusted according to needs of patients. The hospitalization readmission rate and cost of care for heart failure are at an all time high. In 2009, the cost of hospitalization for heart failure care was estimated at 37.2 billion dollars. 1 Heart failure results from lack of blood and oxygen flow to and from the heart to other organs in the body. According to the CDC (Center for Disease Control and Prevention), almost 5.1 million people in the United States suffer from heart failure. 2 It is a common chronic disease that often results in hospitalization and death. At about age 40, one in five people are at risk for developing heart failure. It is also the number one reason for hospitalization among Medicare patients in the Veteran’s Heath Care System. According to the United States Department of Veterans Affairs, within the Medicare health care system, readmission rate for this condition occurs in 20 percent of patients within 30 days of discharge in older adults. 1 Many studies show improvement in CHF management and readmission rates among hospitalized individuals who receive the appropriate follow-up care at the appropriate time post-discharge. Nutrition education plays a significant role in CHF management. Non-compliance with diet recommendations can be harmful for patients with CHF and can also lead to death. Diet plays a major role in not only heart health maintenance after heart failure, but also in prevention of heart disease. Research from World Heart Federation shows that people who follow a diet low in saturated fats, with plenty of fresh fruits and vegetables there is a 73 percent reduction in risk of new major cardiac events. 3 RESULTS REFERENCES • This study population consisted of a total of 14 patients. • The Intern was unable to contact 3 of the 7 patients in the intervention group; they were excluded from the study. • It was found that of the 4 patients that were contacted for follow up education • 1 patient was readmitted for shortness of breath which is a symptom of CHF. • Table 1 summarizes the comparison of the readmissions per group as well as the excluded patients. • In terms of percentages: • 4 patients that received the follow up low sodium diet education via phone 14 days after initial discharge from hospital • 25% were readmitted within 30 days after initial discharge. • Of the patients who received only inpatient low sodium diet education, 28.6% were readmitted within the 30 day period. • Patients from the control group were 3.6% more likely to be readmitted. • The control group consisted of 5 male patients and 2 female patients, 2 male patients were readmitted. • The intervention group consisted of 3 males and 4 females, 1 female was readmitted. • Table 2 summarizes the comparison of gender data for this study. • Patients in this study were between the ages of 46 and 87 years of age. • The 2 male patients who were readmitted from the control group were ages 71and 72, the 1 female patient that was readmitted from the intervention group was 84 years old. INTRODUCTION 1. United States Department of Veteran’s Affair. “Chronic Heart Failure (CHF) Quality Enhancement Research Initiative.” Available at http://www.queri.research.va.gov/chf/. Accessed December 1, 2013. 2. Center for Disease Control and Prevention. “Heart Failure Fact Sheet.” Available at http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm. Accessed December 3, 3013. 3. World Heart Federation. “Diet.” Available at http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diet/. Accessed November 29, 2013. 4. Chen LM, Jha AK, Guterman S, Ridgway AB, Orav EJ, Epstein AM. Hospital cost of care, quality of care, and readmission rates: penny wise and pound foolish? Arch Intern Med. 2010;170(4):340-6 5.Slater MR, Phillips DM, Woodard EK. Cost-effective care a phone call away: a nurse-managed telephonic program for patients with chronic heart failure. Nurs Econ. 2008;26(1):41-4. 6. Rafii F, Shahpoorian F, Axarbaad M. “The reality of Learning Self-Care Needs during Hospitalization: Patients’ and Nurses’ Perceptions.” Self-care, Dependent-Care & Nursing. 2008;(16):34-9. 7. Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. “The Impact of Postdischarge Telephonic Follow- up on Hospital Readmission” Population Health Management. 2009;(14): 27-32. 8. Sharma RK, Dhakarwal P, Violago J, Bhasin R, Ghobrial I. “Tackling the readmission epidemic: a resident teaching service perspective.” J Community Hosp Intern Med Perspect. 2012;2(4) 9. Otsu H, Moriyama M. “Effectiveness of an educational self-management program for outpatients with chronic heart failure.” Jpn J Nurs Sci. 2011;8(2):140-52. 10. Nutrition Care Manual. "Heart-Healthy Eating Nutrition Therapy." Available at https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=107. Accessed January 2, 2014. • The purpose of this study is to find determine if inpatient and post- discharge diet education decrease readmission rates of CHF patients. • Readmission rate and cost of care for heart failure are at an all time high • In 2009, the cost of hospitalization for heart failure care was estimated at 37.2 billion dollars. 1 • According to the CDC (Center for Disease Control and Prevention), almost 5.1 million people in the United States suffer from heart failure. 2 • CHF is a common chronic disease that often results in hospitalization and death. • One in five people are at risk for developing heart failure. • Number one reason for hospitalization among Medicare patients in the Veteran’s Heath Care System. • Readmission rate for this condition occurs in 20 percent of patients within 30 days of discharge in older adults. 1 • Nutrition education plays a significant role in CHF management. • Non-compliance with diet recommendations can be harmful for patients with CHF and can also lead to death. • Diet plays a major role in not only heart health maintenance after heart failure, but also in prevention of heart disease. • Research from World Heart Federation shows that people who follow a diet low in saturated fats, with plenty of fresh fruits and vegetables there is a 73 percent reduction in risk of new major cardiac events. 3 DISCUSSION • When it comes to management of CHF, nutrition plays a vital role as do Dietitians as part of a multidisciplinary care team in acute care settings. • Dietitians provide diet education, promote healthy lifestyle changes, and help individuals modify their lifestyle and diet for CHF management. • At this time, the Registered Dietitians at St. Luke’s Medical Center do not screen and educate CHF patients on low sodium diets as it is not part of their screening criteria. • However, they do provide diet education upon patient request or Physician/Nurse request for nutrition consultation. • Patients that are educated during their hospital stay are not contacted after discharge from the hospital to evaluate understanding and compliance of the low sodium diet. • Patients do have the option of scheduling a visit with the outpatient Dietitian if they chose to do so; this information is provided if patient shows interest in more in-depth nutrition education. • The results were not as significant as anticipated at the beginning of the study. • Two of the 7 patients from the control group were readmitted for symptoms of CHF or CHF within the 30 day period, including shortness of breath. • 1 patient from the intervention group (1 of the 4 patients that were contacted for follow up diet education and questionnaire) was readmitted for shortness of breath, which is a symptom of CHF despite the nutrition intervention conducted via phone post discharge. • Limitations • Small study population and patients are reluctant to participate in study due to required of consent form. • The Intern was unable to contact 3 of the 7 patients in the intervention group for the follow-up diet education. • Questionnaire: • Helpful in establishing the effectiveness of the inpatient CHF diet education. • Many patients did not recall basic information presented to them at the in-patient diet consultation. • None of the patients were able to recall how many milligrams of sodium is recommended to a patient with CHF per day. • Two of the 4 patients stated they follow a heart healthy diet, including sodium restrictions. • One of 4 patients acknowledged that they would like to follow a heart healthy diet but do not, and one patient declared they do not follow a heart healthy diet. • All 4 patients stated they do not add salt to meals at the table or on top of what is used to cook their meals. • All 4 patients also declared they dine out less than 2 times per week. RESEARCH QUESTION / OBJECTIVE • The purpose of this study: • Determine if inpatient and post- discharge diet education decrease readmission rates of CHF patients. • Do patients understand their diet and how it affects their chronic disease. CONTACT INFORMATION For additional information, please contact: Neha Bhakta ARAMARK Dietetic Intern nehagbhakta@gmail.com