The Essentials of Patient Education in the Emergency Department

Robin J. Trupp

Elsie M. Selby

Introduction

Heart failure is a complex chronic condition associated with great morbidity, mortality, and economic burden in the United States. The vast majority of health care expenses related to heart failure occur as a result of hospitalizations for decompensation.¹ Identification of the reason for the decompensation, such as further deterioration in left ventricular function or a remedial cause, determines the treatment plan. Importantly, in most instances, these hospitalizations could be avoided with adherence to treatment regimens and/or careful monitoring and attention to changes in signs and symptoms of heart failure.², ³ and ⁴ Although educational needs for the patient with heart failure are vast and include such topics as the pathophysiology and etiology of heart failure and necessary lifestyle modifications, in an observation unit education must be directed and succinct, given the short-term nature of the interaction. However, during times of stress, as would be expected in patients presenting to an emergency department, retention of any information given is limited.⁵ If the patient is ultimately hospitalized, the urgency for providing information is somewhat lessened, because the inpatient environment offers additional opportunity for, and reinforcement of, education. Because the majority of causes of worsening heart failure are directly attributable to nonadherence to the medication and/or dietary regimens, this chapter concentrates on these topics as essential elements of patient education.

Adherence to prescribed medical regimens, including both pharmacologic and nonpharmacologic interventions, significantly impacts both the short- and long-term management of heart failure. Such treatment strategies have been well proven to slow disease progression, reduce hospital admissions, and improve overall symptom control.⁶ However, despite the importance of these interventions, numerous barriers to adherence exist. Barriers may include lack of understanding of perceived benefit, lifestyle modifications, absence of social support, powerlessness, financial concerns,
and time constraints. These barriers complicate patients’ ability and willingness to adhere to the prescribed medical regimen. In addition, in the haste to shorten length of stay and reduce health care expenditures, clinicians may simply treat the symptoms and fail to identify nonmedical causes for the decompensation. By taking the time to do a thorough assessment to identify barriers and then target problem areas, clinicians can better use the time spent with each patient, leading to a more individualized treatment plan and enhanced adherence.⁷

Causes for Decompensation

Poor compliance with the medication regimen and volume overload, directly related to sodium indiscretion (willful or inadvertent) and/or excess fluid intake, are the major causes for decompensated, or worsening, heart failure.³^,⁸ In many of these instances, improved communication between the patient and health care team could have provided an opportunity to intervene and avoid hospitalization. Using an organized multidisciplinary team affords greater opportunities for achieving treatment goals and outcomes. The success of multidisciplinary teams is well documented in the medical and nursing literature, and much of their success is directly related to enhanced communication, improved adherence, and increased attention to early warning signs of worsening heart failure.

Medication and Dietary Adherence

Diet and medication adherence have profound implications for the management of heart failure. Lack of adherence as a significant cause of decompensation and hospitalization has been well documented.³ Poor adherence also has significant economic repercussions. For example, if insufficient medication is taken for the treatment to be fully effective, as occurs when patients “ration” diuretics to extend the life of a prescription, subsequent health care costs are likely to be incurred as a result of hospital-based treatment. Not unexpectedly, better outcomes are seen with improved adherence to treatment plans.⁶

The role of education on medication and dietary adherence cannot be overemphasized and requires continual reinforcement. Clinicians working with heart failure patients are challenged to approach each patient as unique and to individualize strategies to increase adherence to diet and medication. One size does not fit all here.

Dietary Instructions

In general, sodium intake should be limited to about 2,000 mg per day for all patients with heart failure, regardless of type of dysfunction or the use of diuretics. Because the average American diet consists of approximately 6,000 mg per day, this degree of sodium restriction is challenging for even the most dedicated patient. Counseling should include repeated in-depth
instruction on the components of a 2-g sodium diet and should involve family members as well. Although patients not suffering from advanced disease may be able to tolerate more sodium, limiting intake to 2,000 mg sodium daily is advised because consumption will likely exceed the recommendations anyway. Salt substitutes and spices may be used to improve the palatability of food. However, some salt substitutes replace sodium chloride with potassium chloride and should be used with caution, given the potential risk of hyperkalemia.

In advanced heart failure, further dietary sodium restriction may be necessary to attenuate expansion of extracellular fluid volume and the development of edema. Although sodium restriction may assuage the development of edema, it cannot totally prevent it, because the kidneys are capable of reducing urinary sodium excretion to less than 10 mmol per day. Hyponatremia should not discourage compliance with a restricted sodium diet, because the hyponatremia is usually dilutional in nature and associated with total body sodium and water excess. Liberalized sodium intake or replacement, therefore, should be considered only in overt cases of severe excessive diuresis and dehydration.

Within the emergency department, simple questions about recent dietary intake may yield the cause of decompensation. Accompanying family members are also good sources of information regarding food or fluid intake. Patients should understand the relationship between fluid and sodium for managing volume and in controlling symptoms. Instructing patients to simply take an extra diuretic to relieve symptoms should not be encouraged, because diuretics contribute to increased neurohormonal stimulation and worsening renal function.⁷ Patients should understand that dietary indiscretion produces fluid retention and worsening symptoms. Thus, efforts should focus on helping patients make the association between behavior and symptoms. The challenge lies in doing this without preaching or condemning. Learning will not occur within that scenario. If a connection between a particular behavior and its negative consequences can be made, lifestyle changes are more likely. Behavioral changes do not happen overnight, but those who view the recommended changes as personal choices, rather than as edicts imposed by others, are more likely to make permanent lifestyle modifications.⁸

Recognizing obvious sources of sodium, such as the salt shaker or potato chips, is evident for most patients but in a typical diet constitutes less than 25% of total intake. Hidden sources of sodium play a major role in dietary intake yet are often unrecognized. Good heart failure clinicians are also good detectives. Common high-sodium-content items include, but are not limited to, canned soups and vegetables, pickles, cheese, softened water, tomato juice, antacids, and processed foods. Having the patient complete a food diary over the course of several days will give the clinician important insights into dietary habits and average fluid consumption and will likely reveal unexpected high-sodium sources. Starting this diary after treatment in the emergency department affords the clinician next evaluating the patient
much-needed information and the ability to offer alternative lower sodium choices. Resources available for patients include pamphlets or booklets on the sodium content of foods, for use both at home and when dining out. These materials should be readily located and available within the emergency department. Another more commonly used resource is the Internet, where numerous web sites related to low-sodium food choices and recipes can be located.

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