CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
CARDIAC PATIENT EDUCATION:
AN EVALUATION OF PROGRAM COMPLIANCE·
A project submitted in partial sat·isfaction of the
requirements for the degree of Master of Public Health in
Health Education
by
Judith Ann Krayk
January, 1983
The Project of Judith Ann Krayk is approved:
Michael V. Kline, Dr . . H., Chair
California State University, Northridge
ii
TABLE OF CONTENTS
Page
LIST OF TABLES
v
ABSTRACT
vi
Chapter
1.
2.
INTRODUCTION
Statement of the Problem
2
Purpose of the Project
3
Project Limitations
4
Pertinent Definitions
4
LITERATURE REVIEW
7
Introduction
7
Defining Health Education
7
Health Education:
3.
1
Development as a Profession
10
Evaluation of Patient Education Programs for Chronic
Illnesses
13
Evaluation Studies
14
Documentaries of Health Education Activities
19
Program Evaluation by Hospitals
23
Cardiovascular Diseases and Patient Education Programs
25
Summary
28
METHODOLOGY
30
Phase 1:
Design of Survey Instrument
30
Phase 2:
Identification of the Study Population
34
Phase 3:
Method of Analysis
35
iii
Page
Chapter
Methodological Problems Encountered
4.
5.
RESULTS AND FINDINGS
36
39
Demographic Data Results
39
Medical Data Results
44
Cardiac Teaching Data Results
49
Findings
53
CONCLUSIONS, RECOMMENDATIONS AND SUMMARY
Conclusions
59
60
·Recommendations
63
Observations and Summary
66
SELECTED BIBLIOGRAPHY
68
APPENDIXES
71
A.
CARDIAC TEACHING PROGRAM WORKSHEET
72
B.
CARDIAC EDUCATION CARE PLAN
74
iv
LIST OF TABLES
Table
Page
1.
Sex
40
2.
Age (In Years)
40
3.
Ethnicity
41
Occupation by Sex, Profession and Numb·er in Each
42
5.
Residence
43
6.
Primary Language
43
7.
Usual Medical Provider
44
8.
Other Medical Problems at Admission By Type of
Problem and Rank Order
45
Length of (Hospital) Stay
46
10.
Risk Factors
48
11.
Teaching Contacts and Documentation
50
12.
Documentation of Teaching Modules Omitted and Added
52
. 4.
9.
v
ABSTRACT
CARDIAC PATIENT EDUCATION:
AN EVALUATION OF
PROGRAM COMPLIANCE
by
Judith Ann Krayk
Master of Public Health in Health Education
A hospital patient education program for cardiac patients was
evaluated through the review of medical records.
A questionnaire
was used to collect data from the records of Myocardial Infarction
patients discharged in 1979.
Medical and demographic data collected
about the current target population was compared with data from prior
studies (performed in 1976 and 1978) to ascertain which, if any,
characteristics had changed.
Survey results showed a sharp increase in Spanish-speaking Hispanics
and a greater number of patients who were still employed, rather than
retired, at the time of hospital admission.
Survey data were also
collected regarding the cardiac patient education program.
Survey
findings indicated teaching team members were not adequately documenting teaching activities, post-teaching tests were not being
utilized as assessment tools, and some content areas were not being
taught.
However, the cardiac patient education program appeared to
be an integral part of each cardiac patient's rehabilitation program
as evidenced by physicians' comments.
vi
Chapter 1
CARDIAC PATIENT EDUCATION:
AN INTRODUCTION
Introduction
Over the past two decades, education of patients in an acute hospital
setting has gained acceptance as a right of each patient and as a
responsibility of each hospital.
Numerous studies have sought to
document the benefits of patient education programs and to explore
various administrative, educational and evaluative formats.
As public health issues have shifted from acute problems (e.g., inadequate sanitation, poor hygiene and diseases preventable by vaccination) to chronic diseases (e.g., heart disease and diabetes) and preventive health care, the emphasis in patient education programs has
also shifted.
Programs are geared toward rehabilitating chronic
disease patients to return them to their individual maximum levels of
wellness, to teach them how to live with and control, to some degree,
their chronic disease.
For example, twenty-nine million people in
the United States have a heart or blood vessel disease (American
Heart Association, 1976), and education programs for rehabilitating
cardiac patients help to return them to full function and keep from
re-experiencing a new heart problem.
Although some forms of cardio-
vascular disease may be inherited, patient education programs have
had positive impact by reducing cardiac risks, decreasing hospital
re-admission rates, reducing the length of hospital stays for cardiac
problems, and assisting patients in developing more healthful living
styles (Rosenberg, 1971; Kaye and Hammond, 1978; De Berry, 1975).
1
2
The General Hospital Ventura County (GHVC) has been deeply involved
in patient education.
GHVC is a 203-bed hospital under the aegis of the Ventura County
Health Care Agency.
The Agency serves a catchment population of
530,000 people and includes the areas of Ventura County, Southern
Santa Barbara County and Northern Los Angeles County.
The Patient Education Department at GHVC consists of an M.P.H.
Health Educator who is the department director and one Registered
Nurse who is the primary contact person with patients for teaching.
Other Agency and Hospital staff members assist with some of the inhospital patient educat'ion functions on a limited basis.
It was dur-
ing the Master of Public Health field training internship that this
Investigator began to perceive the need for evaluating cardiac
patient education.
In 1976 GHVC had developed the Cardiac Patient Education and Rehabilitation Resource Guide (hereinafter referred to as Guide).
This
Guide, one of a number of formalized programs developed and implemented by the Patient Education Department, is the resource document
for the cardiac teaching program.
The Guide includes program goals
and objectives, the functions of each team member, curricula (which
is separated into individual teaching modules for each topic area in
the cardiac series), evaluation questionnaires, and a bibliography.
Statement of the Problem
After completing an intensive orientation with the Director of Patient
Education, it was agreed that this Investigator would undertake an
3
evaluation of the teaching program for cardiac patients.
several reasons for this choice.
There were
First, the cardiac program had been
one of the first teaching programs initiated after a 1976 needs
assessment survey.
There was, therefore, a general need to know if
the cardiac program was still pertinent for its target population.
Second, the cardiac program was rather complex in the variety of
"teachers" (e.g., dietician, occupational therapist,
so~ial
worker)
involved with each cardiac patient rather than just the nurse educator, and there had been several changes in the team membership
since 1976.
The Director of Patient Education was concerned with
learning what was happening with the program currently and indicated
a critical n·eed to carry out a more formal evaluation.
Such an
evaluation would be useful in order to determine where modifications
to either the Guide or teaching procedures may be needed.
It was
also recognized that the current target population may be different
from that of 1976 for which the Guide had been developed.
Purpose of the Project
The purpose of this Project is:
1.
to evaluate the current cardiac teaching practices relevant
to determining whether they comply with the teaching practices
documented in the Guide; and,
2.
to gather medical and demographic data on the current cardiac
patient population relevant to determining whether the Guide
continued to be pertinent for its target population.
4
Project Limitations
Medical record documentation presented several problems.
Not all
teaching contacts were documented on the Patient Education Care Plan/
Teaching Checklist (i.e. , some were not documented at all, some were
documented in other portions of the medical record).
Additionally, a few modifications were required in the medical and
demographic data sections of the survey questionnaire.
Therefore,
a direct correlation between the 1979 and the 1976 and 1978 survey
groups could not be made in all areas.
Pertinent Definitions
Admission - a period of time during which a patient is confined to
a hospital for treatment.
Cardiac Teaching Guide - refer to:
Guide
Cardiac Teaching Program - a term which refers to the multiple components of the GHVC patient education activity for patients with
cardiac diagnoses; components include, but are not limited to,
the following:
teaching team members, Guide, day-to-day
teaching activities and attending physician
tre~tment
plan.
Cardiac Teaching Team - a group of health professionals who share
in the teaching of those persons who have heart problems; the
group includes, but may not be restricted to, the following
professionals:
health educator, cardiac care nurse(s), post-
cardiac care nurse(s), dietician, occupational therapist,
physical therapist, pharmacist, and social worker.
GHVC - synonym for General Hospital Ventura County
'
.
5
Guide - an abbreviated title for the Cardiac Patient Education and
Rehabilitation Teaching and Resource Guide; this is the resource
document for the cardiac teaching team and encompasses areas such
as job descriptions, program goals and objectives, curricula
(which is divided into individual teaching modules for each
topic in the cardiac teaching series), and evaluation questionnaires.
Length of Stay (LOS) - the number of days a patient is in the hospital
for the diagnosis and treatment of ea<;h spell of illness; LOS
is derived by calculating the number of days between the day
of admission and day of discharge (NOTE: 'The day of discharge
is not counted as a day of stay.)
Medical Record- written-documentation for each hospital admission
which contains sufficient data written in sequence of events
to justify the diagnosis and warrant the treatment and-end
results of the hospital stay.
Myocardial Infarction (MI) - a medical condition in which the blood
supply to an area of heart muscle is suddenly interrupted,
resulting in the death of that muscle at the site of the interruption (NOTE:
For this project, only those patients whose
final diagnosis - not admitting diagnosis - was MI will be
included.)
Patient - a person who is ill or who is under treatment for a disease.
Patient Education Care Plan/Teaching Checklist (PECP) - this is the
form designed to,enumerate and document in sequential order the
various components of each patient's cardiac teaching program;
6
this form is included as a part of the medical record of each
patient who Rarticipates in any of the GHVC patient education
classes (NOTE:
PECP.)
This form will hereinafter be referred to as
This form is appended as Appendix B.
Chapter 2
LITERATURE REVIEW
Introduction
Selected literature relevant to cardiac patient teaching programs
will be reviewed in this Chapter.
background on
he~lth
In order to provide some general
education .and patient education, a brief overview
of health education will be presented.
Several definitions will be
considered.and the movement toward the growing acceptance of health
education by both the government and the private (i.e., consumer)
sector will be traced.
Studies relevant to evaluating the impact of
patient education programs including the area of cardiac patient
education and methods of program evaluation by hospitals, will be
reviewed.
The final section of the Literature Review will focus on
programs specific to cardiovascular diseases.
Defining Health Education
Consumer demand, rising medical care costs, legal pressures, and
hospital accreditation requirements have influe.nced health care
professionals' concern with patient education.
"A patient who has
not been provided with adequate educational care can no longer be
considered adequately treatedu (Linde, 1979).
Now that the focus
of clinical management for chronically ill patients has become
holistic (that is, more oriented toward caring for the behavioral,
psychological and social difficulties) (Brody, 1980), it is important
that the role of health care has been delineated and health education
7
·8
(whether in the school, community or clinical setting) established as
a profession.
Lawrence Green (1980) defined "health education" as "any combination of
learning experiences designed to facilitate voluntary adaptations of
.behavior conducive to health."
That is to say that health education
is not the dissemination of information nor the demonstration of
health care skills (e.g., brushing of teeth) nor the giving of
directions/instructions (e.g., when to take medications); health
education is, however, specific to health behavior--either in helping
people to maintain their lifestyles or in helping them to develop
lifestyles in health-enhancing directions.
By this definition,
Green (1980) also described health education as an intervention-"the purpose of which is to short-circuit illness or to enhance the
quality of life through change or development of (positive) healthrelated behaviors."
As such, a health education program may serve
to intervene at one of several levels:
primary (hygiene/prevention),
secondary (early detection), or tertiary (therapeutic}.
Green also
emphasized that the overriding principle in any approach to health
education should be that the health behavior is a voluntary behavior
and, when change is recommended, the reason for the change must be
understood and be compatible with one's values.
Redman (1974) defined health education as a therapy (i.e., teaching
is a form of interpersonal influence used to change client behavior).
Redman believed that until the early 1970's, health education, particularly that in health care institutions, had not been widely accepted
and that a strained relationship existed between health educators and
9
the public.
This lack of acceptance was primarily due to the failure
of the public to "conceptualize" (and accept) health education as a
therapy.
By the early 1970's, health education had become clearly de-
fined as a health professional with established standards of practice.
Somers (1976) discussed the preventive mode of health education in a
hospital setting.
~he
believed that hospitals, as a part of their
community health center role, should undertake health education as the
"incidence of nonfatal but preventable (disease) and accidents is
enormous."
The "common denominator" of most preventable morbidity
and premature mortality is individual behavior or lifestyle.
The
average American can be persuaded through education to modify behaviors toward more healthful ways.
Somers noted there has been an
increase in health consumerism (i.e., people who seek out information,
products and advice with which to make decisions for change in health
behaviors and/or lifestyles) as evidence that patients have become
interested and active in what health education has to offer.
The
current economics of health care--specifically, the ever-increasing
costs--provides an ample incentive to the patient/consumer, the
public/government, and private health systems to find ways to prevent
illnesses as well as to better utilize existing resources.
The health education program for cardiac patients at General Hospital
Ventura County (GHVC) exists, for the most part, at the tertiary or
treatment level.
Patients are selected for this program by virtue of
admission to the Cardiac Care Unit and following an acute myocardial
infarction.
The objectives of GHVC's cardiac teaching program are
to help the patient to recover from his/her current attack and to
begin to modify those ideas and habits which may have contributed or
10
could contribute in the future to cardiac problems and cardiac disabilities.
Health Education:
Development as a Profession
For many years, health education had been integrated into many of the
other components of health care and had not been viewed as a
separate, distinct function.
Over the past decade, as the benefits
of health education in health care have been studied and as the nature
of diseases has changed from acute to chronic/degenerative, health
education has blossomed into a profession.
The change was prompted
by the concerted efforts of many people, including health professionals, researchers, legislators and patients/consumers.
At the national level, the federal government began in the early
1970's to exert a leadership role in firmly establishing health
education as an integral part of the total health care picture.
In
1971, the President's Committee on Health Education was appointed,
and, subsequently in 1973, the Health Insurance Benefits Advisory
Council (HIBAC) to the Secretary of Health, Education and Welfare
(DHEW).
This Council then established, for the first time, a
committee on health education which would clarify reimbursement
policies of Medicare and Medicaid in the area of health education
(Somers, 1976) and which utlimately provided the financial incentives
to support health education programs.
Another major thrust of the
President's Committee on Health Education was to focus national attention on health education through their annual reports and recommendations to Congress.
Their first annual report in 1973 resulted in:
11
(1)
the establishment of a Bureau of Health Education in the DREW's
Center for Disease Control; and, (2) a DREW contract with the National
Center for Health Education (NCHE) whose purpose was to s.timulate,
coordinate, and evaluate health education programs (Somers, 1976).
By 1974, the first Congressional bill devoted exclusively to consumer
health education had been introduced and, after passing, public
health education was listed as one of the ten national health
pribrities in the National Health Planning and Resources Development
Act of 1974 (PL 93-641).
Concurrent with the increasing support in the public-government sector, private consumer groups (e.g., the National Cancer Institute and
National Heart and Lung Institute) confirmed their belief in health
education by allocating a greater portion of their budgets to
finance health education programs.
Both of the Institutes currently
fund consumer education and prevention programs that total $40 to $50
million each year (Somers, 1976).
By the mid-1970's, non-government
health education activities were flourishing (e.g., (1) the Fogarty
International Center of the National Institutes of Health and the
American College of Preventive Medicine established a Task Force on
Consumer Health Education; (2) the National Center for Health Education in New York City was organized (Somers, 1976); and (3) the
American Hospital Association was supporting conferences on patient
education and seeking to develop reimbursement mechanisms with fiscal
intermediaries such as Blue Cross).
The National Center for Health Education (Logan, 1976) which was
established in 1975 was to serve as anaction group with an emphasis
12
on research in the area of human behavior.
areas of interest were:
The Center's three broad
(1) the examination of the educational needs
of the worker, (2) the communication lines between the patient and
the health expert, and (3) the determination of the scope of health
education needs at the federal, state and local organizational levels.
Within these areas, the Center's specific functions were to find out
how individuals feel about health in general, what their attitudes
are about the utilization of health care services, how individuals
react to new ideas about health care and what motivates consumers
to change health behaviors.
The American
Ho~pital
Association's (1965) approach to health educa-
tion was from the perspective that hospitals are comprehensive community health centers and, therefore, have the responsibility for
"communication essential to good patient care and for teaching about
health and illness to the ill, their families and the community at
large" in order to motivate people to maintain and prolong their
health.
Physicians involved in hospital health care planning, parti-
cularly those in the
out~patient
clinics, agree with the American
Hospital Association that health education is one of the ways in
which hospitals can extend their participation in preventive medicine.
This has become particularly pertinent during the past two decades
as the control of acute disease has increased longevity to that age
where illness, especially chronic illness, has a higher rate of incidence.
This ultimately has resulted in an increase in:
(1)
the
number of patient visits to medical clinics such as those associated
with ambulatory care centers and teaching hospitals; (2) that portion
13
of each dollar which a consumer spends on health care; and (3) the
degree to which patients are motivated to become "practitioners" of
health care rather than being "recipients" of medical treatment (American Hospital Association, 1965).
The American Hospital Association's
(AHA) Center for Health Promotion (1978) has expended considerable
effort in studying methods of hospital financing of patient education
programs.
The AHA has published a policy statement as well as a
"Patient's Bill of Rights" which stated that (patient) education is
integral to the treatment and care of a patient and is, therefore, a
legitimate part of the cost of patient care.
With the acceptance of patient education as a component of hospital
care, hospital administrators centralized the patient education
functions by designating a department specifically for patient education.
While hospital nursing staff members as well as other hospital
staff personnel (e.g., dieticians and pharmacists) continue their
"education" activities, the patient education department staff are
responsible for the overall development, coordination and assessment
of patient education activities.
Between 1975 and 1978, an AHA
(1980) survey documented a 64.5 per cent increase in the number of
hospitals with operational patient education departments (i.e.,
2,009 hospitals in 1978 as compared with 1,218 in 1975); there were
an additional 296 hospitals who reported they were beginning to plan
for the implementation of a patient education department.
Evaluation of Patient Education Programs for Chronic Illnesses
Hospital patient education programs are most frequently developed for
14
diseases or health problems which are chronic or long-standing in
nature.
For example, of the thirty-four types of programs reported
in the AHA 1978 survey, eight of the programs were for.preventive,
diagnostic, or family planning/post-natal care topics while the remaining programs were specific to illnesses related to cancer, cardiovascular problems, diabetes or habit/conditions such·as smoking and
alcoholism/drug dependency.
Because of this, program objectives
and, subsequently, evaluations must be oriented toward behavioral
changes and not just an increase in patient knowledge.
The feasibility of health education programs with regard to behavior
changes and chronic illnesses (e.g., diabetes, rheumatoid arthritis,
myocardial infarction) has been documented in multiple research
studies as well as in subjective reports.
Education programs can
help patients to better cope by making adjustments to every day living
habits or patterns of behavior which are more healthful.
For example,
major adjustments in terms of profession or job may be required or
preferences in foods, hobbies and leisure time activities may need to
be modified in order for a patient to live his/her optimum within
his/her psychosocial value system and yet within the physical limits
imposed by the chronic illness.
Evaluation Studies
The following are summaries of selected studies which have evaluated
the efficacy of health education programs for chronic illnesses:
St. Peter's General Hospital
Rosenberg (1971) reported hospital admissions and hospital days to be
15
reduced (significant at the 1 per cent level) following a patient education program for Congestive Heart Failure (CHF) patients.
This
study was performed at St. Peter's General Hospital, New Jersey, with
the participation of congestive heart failure out-patients (N=SO) and
their families in a structured, educational program.
Before connnenc-
ing the program, 23 of the SO patients were responsible for 35 of the
hospital admissions and 600 patient days.
At the completion of the
program, there were only six patients who had been readmitted for a
total of 12 readmissions and 148 days.
An additional indication
of educational program success (i.e., correlation between attainment
of knowledge and behavior change) was in the adherence of patients to
prescribed medication and diet regimens which was reflected in 24-hour
urinary specimen analyses (e.g., the amount of sodium excreted over
dietary allowances was reduced from 100.5 per cent to 41.7 per cent).
Rosenberg believed the "project demonstrated .•• educational prescription is a useful tool ••. produced measurable improvement in
congestive heart failure patients."
Lama Linda University Medical Center
Twenty chronic heart disease patients at Lama Linda University Medical
Center (Lama Linda, California) participated in an exploratory study
(Berger and et al, 1975) to test the feasibility and potential of
values clarification methods in patient education programs.
The
investigators wished to know if values clarification methods would
assist the cardiac patient in (1) reviewing his/her lifestyle, (2)
establishing some priorities, and (3) implementing changes in lifestyle within the limitations of his/her cardiovascular disease.
16
Fifteen of the twenty patients became aware of specific conflicts and
were able to set behaviorally stated objectives for themselves.
Al~
though some limitations were reported to the values clarification
approach (e.g., severity of illness, patient denial, and "old age"),
the investigators concluded· that values clarification· "appears to be
an effective educational approach for many cardiac patients" as well
as for other illnesses or conditions which require lifestyle changes.
Stanford University School of Medicine
For
rheuma~oid
arthritis patients at the Department of Medicine and
Health Education Center at Stanford University School of Medicine,
Palo Alto, California (Kaye and Hammond, 1978), the program evaluators
recommended patient education "as an effective means of helping
patients (who have a chronic disease) understand arid hence comply
with physicians' instructions, as well as helping (patients) to
assume greater responsibility for their own health."
This recommen-
dation was the result of a study in which pre- and post-education
questionnaires were administered to patients(N=48) and the average
pre-education questionnaire score was 66.6 per cent and the average
post-education questionnaire score was 90.5 per cent.
Additionally,
utilizing the Student T Test for 2 means, the P value was less than
.005 and for paired observations the P value was less than .001-both of which indicate the
highly significant.
increa~e
in patients' information to be
On subjective evaluation of the education pro-
gram, 95 per cent of the patients felt the program was helpful in
improving (1) understanding of the disease, (2) medication compliance,
and (3) communication with their physician and family.
From
17
objective data, 85 per cent of the patients showed actual behavior
changes:
(1)
not abusing their joints (63 per cent); (2) getting
more rest (56 per cent); and, (3)
(48 per cent).
using medications more meticulously
With regard to attitudinal changes, 42 per
~entre­
ported positive changes in feelings about themselves and 54 per cent
reported positive changes in feelings about their disease.
University of Michigan Hospital
Linde and Janz (1979) studied the effects of a structured vs nonstructured patient education program on the knowledge and compliance
of coronary by-pass and valve replacement patients.
Those patients
who participated in the structured education program showed a significant increase in their knowledge scores from the preoperative test
to both the pre-discharge and post-discharge tests using the
Retelling's T-Square Test.
Additionally, those same patients had
higher rates of compliance (i.e., all compliance measures were significant at .01 level).
(NOTE:
For the purposes of this study,
compliance was 'defined as follow-through on recommendations and
therapy prescribed by the appropriate health care practitioner.)
Johns Hopkin Center for Health Services Research
Green and Levine (1979) at Johns Hopkin Center for Health Services
Research, designed a behaviorally-oriented study of three educational
interventions for the control of essential hypertension.
The study
objectives· not only included the efficacy of the interventions but
also the evaluation of the educational program itself.
Green and
Levine reported that those persons in the educational program which
included all three interventions increased blood pressure control by
18
28 per cent over the control group due to:
(1) better compliance to
medication regimens (53 per cent reported high compliance vs 40 per
cent in the control group); (2) a weight reduction of at least 2.kg.
(56 per cent of those in the educational group vs 35 per cent in the
·control group); and, (3) an increased proportion of patients keeping
appointments (76 per cent of those in the educational program vs 63
per cent in the control group).
Me Master University Medical Centre, Ontario, Canada
Sackett (1975) and colleagues, in a study designed to improve medication compliance in a group of 230 Canadian steelworkers with primary hypertension, concluded that a patient education program which
focuses only on increasing the knowledge level of the target group and
disregards techniques for behavior change does not result in patient
compliance with a drug regimen.
Although the majority of those
steelworkers who had participated in the "mastery learning program"
(i.e., the educational program which provided facts about:
hyper-
tension and its effects upon target organs, health, and life expectancy; the benefits of antihypertensive therapy; the need for compliance with medications; and simple reminders for pill-taking) did have
higher test scores relative to factual information about hypertension
and its treatment than those men who were not provided with the
"mastery learning program," the rate of compliance to drug therapy
was essentially the same at 53 per cent (mastery learning group) and
48 per cent (non-mastery learning group).
19
Documentaries of Health Education Activities
The literature which was reviewed above was that.where evaluation of
health education programs was done in a more structured, formal manner
and/or following research protocol.
There are, however, a multitude
of health education activities reported in the literature which are
positive toward health education but are based more on subjective
opinion and/or less stringent data collection and analysis.
Hospital Health Education Project
One such health education activity was reported by the College of
Medicine and Dentistry, Martland Hospital, Newark, New Jersey (Lazes,
1977).
When members of the hospital staff as well as several com-
munity groups became concerned with improving the accessibility and
quality of care in the Newark connnunity with the hospital as the focal
point of health resources, the Health Education Project (HEP) was
established.
The objectives were targeted toward the development of
tangible ways to enable the public to have greater control over factors
which could improve health in those areas where there were high-risk
he~lth
and preventive health issues.
The HEP consisted of setting
aside an area in the hospital outpatient clinic waiting room where
information (via posters, pamphlets, videotapes, discussion groups
and small workshops) could be disseminated by hospital and patientconsumer volunteer staff.
The HEP was considered a "success" when
(1) there continued to be an increase in the number of patients visiting the HEP (262 patients in February 1975 up to 727 patients in
February 1976; (2) the demand was ·great enough to warrant adding additional sessions (e.g., in February 1975 there were 38 sessions but by
20
February 1976 there were 114); and, (3) there began to be a delineation
of problems or needs (e.g., 15 per cent of the clinic patients' charts
were found not to be available for screening and follow-up prior to
their appointment; 42 per cent of the laboratory reports never reached
patient's charts) and problem resolution initiated.
Health Financing and Health Education
In a study on the correlation between
increase~
financing for medical
treatment and its effects on longevity, Forbes (1967) notes that in
countries in which the level of care is fairly sophisticated yet
where degenerative diseases predominate over infectious ones as
causes of death, the controlling factor for health and, specifically,
longevity is a cultural one rather than through the utilization
and/or development of sophisticated modes of medical treatment.
As
such, Forbes purported there would be no significant change in
longevity whether the dollars spent on medical treatment is halved or
doubled.
If one accepts Forbes' conclusions, health education--
which is targeted at psychosocial aspects of patient care--in the
United States could be a viable resource in the treatment of degenerative as well as chronic diseases.
Health Education for Physical Fitness
At the University of Arkansas Medical Center (Doublas, 1975), physicians in the Non-Invasive Laboratory observed that "(1) individuals
with physically demanding occupations generally have a lower rate of
coronary artery disease than those with sedentary jobs; (2) physically
fit, conditioned individuals have a better chance of surviving all
types of physical insults; and (3) patients with coronary
artery~~
21
disease can show dramatic improvements" when they participate in a
physical training program which includes patient education training
(e.g., 70 per cent can return to work within six months, while "benign
neglect" returns only 20 per cent to work).
For "optimal" results
of treatment, patient educatic;m should be included as an integral
part of the rehabilitation regimen.
Health Education and Drug Compliance
In an effort to help cardiac patients develop adequate self care
habits with regard to managing.medications after leaving the hospital,
staff members (De Berry, 1975) in the outpatient cardiology clinic
at North Carolina Memorial Hospital developed a teaching unit specifically on out-patient use of medications.
This unit was utilized on
a pilot basis, evaluated, and subsequently integrated into the hospital's overall cardiac rehabilitation program.
There were 29 cardiac
patients (17 men, 12 women) in the pilot study--all of whom were to
be discharged from the hospital on one or a combination of the
following drugs:
an antiarrhythmic, an anticoagulant, a digitalis
preparation, or a diuretic.
A brief oral pretest was given to each
patient to determine knowledge regarding his/her medications (i.e.,
name of medication, what it is for, how the drug affects the body,
when to phone a physician, when and how much medication to take,
diet precautions and whether or not unprescribed medications were
going to be taken).
Each patient was taught on a one-to-one basis
in 15- to 30-minute sessions.
Prior to discharge from the hospital
each patient was given the same test as that of the pretest and
his/her actual gain was compared with his/her possible gain and a
22
percent of improvement derived.
All 29 patients showed improvement
from the pretest to the post.test; three patients achieved 100 per
cent improvement, and of the remaining 26 patients, the minimum gain
was 33.3 per cent and the average was 71.4 per cent.
In addition, the
teaching staff noted that the presence of family members during the.//
teaching sessions appeared to help motivate patients and reinforce
the teaching.
The teaching staff concluded that in-hospital, pre-
discharge teaching about medications was effective for patients as
well as realistic for use by nurses in the hospital and clinic.
With
a few modifications, the predischarge medication teaching unit was
recommended for inclusion in the overall cardiac rehabilitation teaching program.
Physicians as Health Educators
Physicians, who usually are considered to be the primary patient
educator or the teaching team leader, frequently lack expertise as
managers and educators.
In an effort to improve patient compliance
in a hypertension treatment program at Johns Hopkin Hospital (Inui,
1976), physicians were tutored on hypertension and its therapy and
patient compliance problems.
The study design was quasi-experimental,
with "before" and "after" observations made on control and experimental groups of physicians (N=62) and their patients (N=ll9).
exposure to one tutorial session, tutored
After
physicians allocated a
greater percentage of each clinic visit to patient teaching.
This
resulted in tutored patients scoring higher on tests regarding knowledge of their drug regimens and dietary requirements as well as
more appropriate beliefs with respect to the implications of hyper-
23
tension.
Additionally, tutored patients were found to have better
control of their blood pressure.
Inui and colleagues believed these
findings to have important implications for the management of hypertension and other chronic health problems where achieving improved
patient understanding and compliance may be critical to the endresults of care.
Motivation for Self Care
In
a
review of the (clinical) management of patients with Myocardial
Infarction, Wenger and Felner (1979) commented that both the
patient and the family should be given enough information with which
to assume some responsibility for self care.
Additionally, Wenger
and Felner noted that psychological problems associated with cardiovascular diseases can be reversed with a program of patient education
and a progressive physical activity regimen.
Through the modification
of coronary risk factors, the potential for preventing reinfarction
and sudden coronary death can be reduced.
As risk factor
modifica~
tion is essentially the modification of habits, it requires the
patient's decision to make these changes.
Wenger and Felner sug-
gested that it is the physician's role to provide the motivation,
information and reinforcement to help the patient to make these
changes successfully.
Program Evaluation by Hospitals
The evaluations cited above were, for the most part, performed by
researchers, agencies, and/or other types of outside consultants
whose specific task was to evaluate the efficacy of patient education
24
programs.
Very few patient education programs, including those which
are hospital based, have evaluation components which can be utilized
to document program impact.
In fact, only 4.2 per cent of those
hospitals who participated in the American Hospital Association (1980)
survey reported having statistics about the impact of any of their inpatient education programs and only an additional 20.4 per cent indicated they were even planning to implement some type of formal evaluation protocol.
Of those hospitals who responded "yes" to performance of program
evaluations, there was a wide range of methods reported:
27.7 per
cent chart audit, 11.8 per cent participant counts, 26.2 per cent
"reactionary" questionnaires, 17.9 per cent clinician/patient assessments/tests (some pre/post test, some including demonstration), 21.0
per cent post-discharge follow-up reactionary questionnaires/phone
calls, 8.7 per cent research study, 6.1 per cent "other," 10.3 per
cent method not known.
This data reflects not only the variety of
"evaluation" methods but also the orientation toward evaluating
individual patient's knowledge or attitudes rather than those of
programs.
The use of chart audits and reactionary questionnaires
would be "information collection" and could measure, at best, short
term program impact.
This may, however, be the most appropriate
method for inpatient programs that generally have limited contact
with patients over time as well as limited financial and/or staff
resources.
25
Cardiovascular Diseases and Patient Education Programs
\,____
Because this project deals specifically with a patient education~'',
".
'l
,'
//
teaching program for cardiac patients, it is necessary to include
,/
(
some information on cardiovascular diseases and their prevalence.//
j
The purpose of this information is to provide the reader with some
basic foundatiort on the nature of a cardiac disease, such as ni:yo-:
cardial infarction, as it relates to in-hospital patient teaching programs.
One reason for an increase in hospital cardiac teaching programs is
the prevalence
ofhec:1rt disep,13es.
\---··-,
Each year in the United States,
one million deaths are caused by cardiovascular diseases (i.e.,
diseases of the blood vessels and heart).
This is greater than the
total number of deaths from all other leading causes of death which
include:
cancer (400,000 deaths per year), accidents (108,000 deaths
per year), pneumonia and influenza (58,300 deaths per year), diabetes (37,800 deaths per year), and all other causes combined
(343,100 deaths per year).
Nearly 40,000,000 Americans have one
of the major forms of heart and plood. vessel disease.
Estimated
/'"'''
costs for cardiovascular health care in 1981 exceeded $46.2 billion
(~erican
Heart Association, 1981).
A second reason for the development of hospital teaching programs
directed at cardiovascular diseases is that cardiovascular diseases
are non-acute (i.e., ch;on:[.c) and patients can benefit during their
hospital stay from a teaching program which focuses on
cha11_~~s
in
patients' behavior, rather than just the distribution of pamphlets or
showing of videotapes with the hope than an increase in patients'
"'··
26
knowledge and understanding will be beneficial and/or useful in improving and maintaining health.
The American Heart Association (1980)
survey of patient education programs documented an increase in the
number of cardiovascular programs (i.e., in 1975 cardiovascular programs were ranked sixth with 1,263 programs in operation and by 1978
cardiovascular programs were ranked second with 1,581 programs).
Within the broad term "cardiovascular diseases" there are grouped
several major diseases:
high blood pressure, atherosclerosis,
heart attack, stroke, congestive heart failure, rheumatic heart
disease, and congenital defects.
From the American Heart Association
19~n data, the "~Umber one kiLLer" among the cardiovascular diseases
is heart attack which yearly causes an estimated 641,000 deaths with
an additional estimate of 4,330,000 people who have a prior history
10\
of heart attack.
When one has a heart attack, there is a sudden, acute onset of pain
or uncomfortable feeling of pressure, fullness or squeezing in the
chest which may spread to the shoulders, neck or arms and which may
last for two or more minutes.
Other symptoms such as severe pain,
dizziness, fainting, sweating, nausea or shortness of breath may
also occur.
The symptoms of a heart attack are the result of a
sudden blockage in an artery which supplies the heart with blood,
and, subsequently this results in a myocardial infarction or "death"
of that part of the heart muscle which is not supplied oxygen and
nutrients.
However, this sudden blockage or infarct is usually due
to a slow-developing atherosclerosis (i.e., narrowing of the
coronary arteries) which can be detected on physical examination and
27
treated (American Heart Association, 1981).
Clinically, the diagnosis
of Myocardial Infarction requires two of the following three factors:
(1) a history of chest pain compatible with myocardial ischemia,
(2) abnormal Q waves or appropriate serial ST-T electrocardiographic
changes, and (3) an· appropriate temporal rise in cardiac serum enzyme
levels (Wenger and Felner, 1979).
There are other warning signs or
ri~!<
:f:a(!tors whic:h. !ll<lY 1Je precursors
to a heart attack (American Heart Association, 1981); these include:
(1) heredity - a tendency toward cardiovascular disease which can be
<,:"i_;·~ ~···'·' ·~
inherited;
(2) sex - men are more likely to have heart attacks than women, although the risk for women increases after menopause;
(3) race- Black.Americans are almost 50 per cent more likely to have
high blood pressure;
(4) age - death rates for heart attacks and strokes increase with age;
(5) cigarette smoking
smoking increases heart attack risk;
(6) high blood pressure - there is a high correlation between high
blood pressure and strokes and heart attacks;
(7) serum cholesterol.- higher than normal levels or serum cholesterol
.,~-·
contribute to the progression of atherosclerosis;
(8) diabetes - diabetes (or a familial tendency toward diabetes) is
associated with an increase in risk for cardiovascular diseases;
(9) sedentary life styles - people who have sedentary life styles have
ci.h.igher risk ()f cardiovascular diseases than people who get regular exercise;
28
(10) stress - stress which is not coped with effectively may, over
time, contribute to cardiovascular diseases.
Cardiovascular patient education programs may have objectives specific
to (1) prevention, (2) treatment/management, and/or (3) rehabilitation.
Preventive programs are important as preventive measures (e.g., early
recognition of heart attack risk factors and warning signs) may alleviate a heart attack or stroke (American Heart Association, 1981).
Programs for patients with cardiovascular disease are also beneficial
as "patients with cardiovascular diseases are appropriate candidates •••
as the management of cardiovascular diseases often takes place over a
long period of time ••• effects many body functions •.. helps to clarify
many misunderstandings and misconceptions ••• and frequently requires
the patient to make major behavioral changes" (Redman, 1974).
Summary
The literature reviewed in this Chapter treated several areas and
ideas of pertinence to this Project.
First, patient teaching programs
in hospitals is a relatively new resource for patients.
It was not
until the early 1970's that "patients' rights" and consumerism in
the health care industry began to emerge.
Subsequently, as the
benefits associated with patient education programs were recognized,
hospital departments were established that could provide a comprehensive and coordinated approach to teaching patients.
Second, patient education was defined to include that level of teaching which has objectives specific to behavior change and not limited
to the attainment of knowledge or comprehension.
Change in behavior
29
is pertinent to all levels of health care
(i.e.~ prevention~
diagnosis
and treatment) but is particularly beneficial in the treatment arena
where the nature of illness has become chronic or iong-term and not
particularly responsive to various therapeutic modalities.
Third, the evaluation of patient education programs was reviewed from
the following perspectives:
a)
published research studies that documented positive impact of
patient education were summarized;
b)
less formal studies and/or opinions published in trade journals
were reported; and,
c)
statistics which indicated the general lack of and/or limitations
on patient education program evaluations by hospitals were cited.
Fourth, the prevalence and nature of cardiovascular diseases (e.g.,
being ranked as number one among those illnesses which cause a large
number of deaths annually) makes them a prime subject for patient
education programs in hospitals.
Chapter 3
METHODOLOGY
The primary purpose of this Project was to evaluate the teaching practices specific to the cardiac patient education teaching program at
General Hospital Ventura County (GHVC) and to determine whether they
complied with the teaching practices documented in the "Cardiac
Teaching Guide."
A second purpose of this project was to obtain
medical and demographic data on the current (i.e., 1979) cardiac
patient population to compare with the data from previous (i.e.,
1976 and 1978) cardiac study groups.
The method selected for the evaluation of the cardiac teaching
program as well as for obtaining patient data was a survey of the
medical records of all patients with a final diagnosis of Myocardial
Infarction who were discharged from GHVC in 1979.
describe how the survey
in~trument
This Chapter will
(see Appendix A) was developed,
pre-tested, and, subsequently, utilized; how the population for the
study was selected; and, how the survey data was analyzed.
Phase 1:
A.
Design of Survey Instrument
Evaluation of Other Survey Instruments
Prior to the development of the survey instrument used for the
study, instruments were evaluated which had been utilized by
GHVC's Patient Education Department for prior studies in 1976
and 1978.
The Director of Patient Education used an instrument in 1976
for conducting a needs assessment prior to initiating the cardiac
30
31
teaching program.
However, the instrument was limited to only
collecting information which would elicit data specific to medical
and demographic characteristics of the 1976 cardiac patient.
For
the 1978 study, the Director of Patient Education again utilized
the 1976 instrument for the collection of medical and demographic
data but added a second page which contained questions which
would elicit data relative
t~
the completion of the Patient Edu-
cation Care Plan/Teaching Checklist form.
B.
1979 Survey Instrument.:
Cardiac Teaching Program Worksheet -
1979 (see Appendix A)
After consideration of (1) data collected from the two prior
studies, and (2) the need for comparative demographic and medical
data, the 1979 survey instrument was developed by the Investigator (see Appendix A).
1.
Content of the Instrument
a.
Medical and Demographic
The demographic and medical data items from the 1976
and 1978 instruments were included in the 1979 instrument.
Revisions were made to enable the medical
d~ta
retrieved to be more clearly defined than had been in
the 1976 and 1978 studies.
Minor revisions were made in the wording on those items
which inquired about the number and dates of prior cardiac and non-cardiac admissions, the diagnosis on these
admissions, and the length of stay on each admission.
This information could be utilized to determine if a
32
patient's prior history might effect his/her current or
future cardiac condition, and, subsequently, the rehabilitation and teaching objectives.
b.
Patient Education
The,patient education needs assessment instrument utilized
in 1976 had not contained items pertinent to patient
education program performance.
The 1978 instrument had
contained only five items specific to the patient education.program.
However, this portion of the study had not
been completed.
The patient education portion of the survey instrument
for 1979, therefore, was different from those prior instruments.
Although most of the 1978 items were included
with some minor revisions of wording and sequence, there
was a major revision regarding the collection of information to document (patient education) teaching.
This
particular data item was modified in order to elicit data
regarding which of the cardiac education modules (i.e.,
topics) were taught and on which day of stay, and by
which team member.
2.
Format of the Instrument
With one exception, the 1979 survey instrument utilized the
questionnaire style format so that the person performing the
medical record audit needed only to fill in a blank with a
brief response (e.g., Age: 68) or check the pertinent response
(e.g., Sex:
male,
female).
33
A major exception to this format was the "grid" approach
utilized for documenting the teaching.
The horizontal axis
of the grid was Day of Stay (DOS) while the vertical axis
included a listing of the cardiac teaching modules.
C.
Pre-Testing the Instrument
The 1979 survey instrument, Cardiac Teaching Program Worksheet1979 (Worksheet), was pre-tested by the Investigator on two cardiac
patient medical records.
Although the Worksheet format was ade-
quate, other information observed in the medical records appeared
to be pertinent and consideration of a change in content was
necessary.
D.
Revision of the Instrument
After extensive discussion with the Director of Patient Education, three additional questions were included on the Worksheet
as write-ins in the "Connnent" section.
The additional information to be collected included:
1.
The extent to which physicians completed the Cardiac Rehabilitation form.
(NOTE:
Currently, this form is optional.
But,
when utilized it was helpful in specifying the time or day
of hospital stay on which a physician orders each new
stage of rehabilitative activity.
This was helpful to mem-
bers of the nursing staff and teaching team when they worked
with a rehabilitating cardiac patient.)
2.
The number and types of risk factors documented in each
patient's medical record.
(NOTE:
The eight risk factors
identified for inclusion in this study were:
smoking,
34
heredity, alcohol, obesity, stress, hypertension, rheumatic
heart disease, and prior cardiac history.)
3.
"Was patient educati.on specifically mentioned in the Physician's Discharge Summary?
Yes/No"
(NOTE:
This question
was to assist in determining to what extent the medical staff
had become aware of the cardiac teaching program since its
inception in 1976.)
E.
Data Retrieval
Definition of each item on the survey instrument as well as
specific instructions for retrieval may be requested from the
Investigator.
Phase 2:
A.
Identification of the Study Population
Patient Education Department "Contact Records"
The Patient Education Department "Contact Records" for 1979 were
reviewed.
A list was then made of patients who were visited by
the Patient Educator at least once for the purpose of cardiac
assessment or teaching.
The list contained each patient's full
name (when available) and his/her medical record number.
B.
Medical Record Department Diagnosis Index
The Medical Record Department Diagnosis Index was utilized to
retrieve the name and medical record number of patients who were
discharged during 1979 with a final discharge diagnosis of Myocardial Infarction.
C.
Target Population for the Study
After comparing the two lists and deleting duplicate names or
35
names which were not complete enough for specific identification,
42 patients were identified as having cardiac teaching contacts
or a final diagnosis of Myocardial Infarction.
D.
Revision of Target Population for the Study
Medical record request forms were completed for all 42 patients'
medical records.
After a review of these medical records, eight
of the records were deleted from the study as they proved to be
non-cardiac hospital stays or cardiac problems other than
Myocardial Infarction.
Thus, the total number of records used
in this study was 34.
Phase 3:
A.
Method of Analysis
1979 Data
All Worksheets were numbered sequentially as each was completed.
A tally sheet was made and all answers were recorded on this
sheet.
All tabulating was done by hand since the survey popula-
tion numbered only 34.
After the total number ("N") for each
response was counted, its percent of the total number of responses for that question was calculated.
Tables were then formatted for each survey item in order to
display, where possible, the 1976, 1978, and 1979 data for
comparison.
Both the N for each survey item and its percent
of the total survey population were included in the tables to
determine if and where changes had occurred.
36
Methodological Problems Encountered
As the Investigator proceeded, several methodological problems were
identified which could possibly limit the evaluation outcomes.
These
problems occurred in the following areas:
A.
Medical Record Documentation
The following types of problems related to medical record documentation were encountered:
1.
Data retrieval was a slow and arduous process since the documentation of information was not always stated on the required
or suggested record forms.
This Investigator was forced to
read entire medical records in order to obtain as much data
as possible relevant to completing each questionnaire (e.g.,
The documentation regarding patient education contacts was
infrequently documented on the Patient Education Care Plan/
Teaching Checklist, but was documented on other medical
record forms such as Occupational Therapy Record, Progress
Notes, and Nursing Notes.).
2.
Some data (e.g., risk factors) were not always explicitely
stated.
Therefore, at times, assumptions were made with
regard to individual patient information (e.g., Data on a
female patient who was 5'1" in height and weighed 165
pounds may be construed to have a weight problem even
though the attending physician did not state such a condition
in the medical record.).
37
3.
Those patients who had more than one admission to GHVC had
unit medical records which also contained data on more than
one hospital stay.
The Investigator, at times, found discre-
pancies between the data of different hospital stays for the
same patient.
4.
Information which should have been documented was lacking
(e.g., The Investigator was aware of teaching contacts via
Patient Education Department "contact records" but, at
times, no documentation was available in the medical record.).
B.
Comparability Between 1979 Data and 1976, 1978 Data
The 1976 data had been collected as part of a needs assessment
effort to establish priorities for the Patient Education Department.
Although most of the medical and demographic data items
were still pertinent and useful for purposes of a comparative
study of the target population, patient education activity data
was not available for evaluating program changes and performance.
Although the 1978 survey questionnaire contained several data
items specific to patient education activity, the 1978 study
had not been completed (i.e., most, but not all, of the data
had been collected and the data collected had not been summarized
nor reported).
Additionally, although data retrieval instruc-
tions and definitions for all three studies were discussed with
the Patient Education Department Director, the knowledge and
skill levels of the three investigators were different.
This
could negate the repeatability of each of the studies for purposes of obtaining the same reported results.
38
C.
Changes in the Patient Education Teaching Team Composition
In the three years since the cardiac patient education teaching
program had been initiated, all of the teaching team members had
changed.
Therefore, the Investigator inferred the likelihood that
continuity of teaching program procedures was lacking.
Observa-
tions made by the Investigator, and discussions with the teaching
team members, indicated that team members were not consistently
performing pre/post teaching assessments nor completing the
Patient Education Care Plan/Teaching Checklist.
Also, teaching
content was at times different from that appearing in the program
Guide.
D.
Changes in the Cardiac Care Unit (CCU) Composition
When the cardiac teaching program was initiated in 1976, the CCl],,
and ICU (Intensive Care Unit) were combined.
At the time of this
evaluation, a new and separate CCU had opened which could accommodate six patients and which was staffed on a one-to-one basis.
With such intensive staffing, the CCU nurses were assuming a
greater portion of the teaching and, potentially, could continue
the teaching program after the ca_:t::cl.icac pa,tient was transferred
to a medical ward.
'
I
Chapter 4
RESULTS AND FINDINGS
The purpose of this Chapter will be to present results and findings
of the study regarding cardiac patient education for patients discharged in 1979 with a diagnosis of Myocardial Infarction.
Results
where comparable to studies performed in 1976 and 1978, are reflected
in this summary as well as in the data displayed in tables throughout
the Chapter.
Results
DEMOGRAPHIC DATA RESULTS
Initially, from Patient Education Department and Medical Record Department records, 42 patients were identified for inclusion in the
1979 study.
After chart reviews, eight patients were eliminated
from the study as they were either non-cardiac or non-Myocardial
Infarction patients.
Therefore, the 1979 study population was 34.
For the 1978 study, 34 patients had been initially identified; but,
as some medical records were not available or were not Myocardial
Infarction patients, the 1978 study population was 21.
study population was 47.
The 1976
In 1979, 23 (67.6 percent) of the patients
were male and 11 (32.4 percent) were female.
When comparing 1979 to
both the 1976 and 1978 study groups (see Table 1), it appeared the
number of male patients decreased slightly after the 1976 study and
had remained at 67 percent for both 1978 and 1979.
Conversely, the
number of female patients increased slightly from 30 percent in 1976
to 33 percent of the population in 1978 and 1979.
39
40
Table 1
Sex
1976
1978
Percent
N
1979
Percent
N
Percent
N
Male
33
70.2
14
67.0
23
67.6
Female
14
29.8
7
33.0
11
32.4
Total
47
100.0
21
100.0
34
100.0
Although the mean age (see Table 2) had not changed substantially
from 1976 to 1979 (64.. 9 year to 61.9 year respectively), the female
patient population mean age dropped seven years--from 69.5 years
Table 2
Age (In Years)
1976
N
Male
%
-
X
1978
RANGE
%
1979
RANGE
N
%
-
X
RANGE
33 70.2 60.3 30-83 14 66.6 60.4 29-84 23 67.6 61.8 32-88
Female 14 29.8 69.5 44-85
Total
N
-X
7 33.4 60.7 45-74 11 32.4 62.0 44-75
14 100.0 64.9 30-85 21 100.0 60.5 29-84 34 100.0 61.9 32-88
(1976) to 62.0 years (1979).
The upper range for females dropped ten
years, from 85 to 75 years of age.
The mean age of male patients re-
mained around 61 years of age and the upper range remained in the 80's.
41
The ethnicity of Myocardial Infarction patients (see Table 3) continued to be predominantly Caucasian.
However, there was a substantial
increase in the number of Mexican-American patients--from one in 1976
to seven in 1979.
Table 3
Ethnicity
1976
%
N
Cauc
M 32
F 13
Tot 45
M
MexAm F
Tot
0
1
1
M
F
Tot
1
0
1
Other
1978
N
97.0
92.9
95.7
-
7.1
2.2
3.0
-
2.2
1979
%
%
N
12 85.6 18
7 100.0 9
19 94.4 27
78.3
81.8
79.4
7.2
5
2
7
21.7
18.2
20.6
0
0
0
-
1
0
1
1
0
1
4.8
7.2
-
4.8
As in 1976, no one type of occupation was dominant.
In 1979, only
8.7 percent of the males were retired; this was a sharp drop f+om
1976 when 36 percent of the males were retired.
of the females were retired.
patients' occupations.
In 1979, 9.1 percent
Table 4 discloses the breakdown of
Fifty percent of the charts had occupation
recorded on the History Report; the Social Service Record, Consultation Report, and Occupational Therapy Record each had 5.9 percent;
and the Physical Therapy Record and Patient Education Assessment form
each had 2.9 percent.
42
Table 4
Occupation by Sex, Profession and Number in Each
1979
II
MALES
II
FEMALES
2
1
1
1
1
2
1
1
1
1
1
1
3
2
1
1
1
1
1
1
1
-4
Real Estate Broker
Housewife
Dog Groomer
Minister
Teachers Aid
"Works" - Not Specific
Retired
Not Stated
4•
College Professor
Helicopter Crewman
Bus Driver
Locksmith
Ranch-Crop Sprayer
Company Pres. /Owner
Photographer
Local Salesman
TV Repairman
Field Worker
Elevator Operator
Microfilm Technician
"Works" - Not Specific
Retired
Not Stated
23
Total
11
.....
Total
Additionally, 26.5 percent of the patients' charts lacked documentation of employment status; only 73.5 percent of the patients' charts
had occupational status recorded.
The majority of the 1979 patients (91.2 percent) lived either in the
City of Ventura.or other cities in Ventura County (see Table 5); this
is much the same as for the 1976 and 1978 patients' residences.
One
patient lived in Santa Barbara County, one in Los Angeles County, and
one lived out of state but was visiting children in Ventura.
43
Table 5
Residence
1976
1978
N
%
N
Ventura City
23
48.9
10
Other Vent. Cnty.
10
21.3
Other Calif.
3
Out of State
Not Specified
1979
%
N
%
47.6
21
61.8
6
28.6
10
29.5
6.4
5
23.8
2
5.8
2
4.3
0
-
1
2.9
9
19.1
0
-
0
-
As in the previous two studies, only a few of the patients were
Spanish-speaking only; however, there does appear to be a slight
trend upward in the percent of patients who do not speak English
(1976- 2.1 percent, 1978- 4.8 percent, 1979- 11.8 percent).
Table 6 for Primary Language.
Table 6
Primary Language
1978
1976
N
%
N
1979
%
20 . 95.2
English
46
97.9
Spanish
1
2.1
1
Other
0
-
0
N
%
30
88.2
4.8
4
11.8
-
0
-
See
44
The primary medical provider of most patients (see Table 7) continued
to be the private physician.
As in both 1976 and 1979, 70 percent
of the patients reported private physician care and 30 percent reported to have either Hospital Outpatient Clinics or other sources of
health care.
Table 7
Usual Medical Provider
1976
N
Priv.
Phys.
1978
%
N
1979
%
N
%
33
70.2
5
23.8
24
70.6
Hosp.
Clinic
2
4.3
4
19.0
10
29.4
Other
8
17.0
3
14.3
0
-
Not
Specfd.
4
8.5
9
42.9
0
-
Total
47 100.0
21 100.0
34 100.0
MEDICAL DATA RESULTS
All of the 34 patients in the 1979 study had a primary discharge
diagnosis of Myocardial Infarction.
Unlike the 1976 study where
five (10.6 percent) of the patients had expired shortly after admission, none of the 1979 patients expired.
However, two patients
did expire after discharge--one expired four months later at home
and the second patient expired four months later during a subsequent admission.
45
Other Medical Problems
More of the patients in 1979 were admitted with one or more other
medical problems (see Table 8).
In 1976, 28 (59 percent) reported
Table 8
Other Medical Problems at Admission
By Type of Problem and Rank Order
1979
Rank
1
2
3
4
4
4
4
5
5.
5
Problems
Congestive Heart Failure
Hypertension
Obesity
Arrhythmias/Fibrillations
COPD
Arthritis
Diabetes
Angina
Asthma
Pneumonia
other medical problems, whereas, in 1979, 26 (76.5 percent) had
other medical problems.
The problems were similar and included:
Congestive Heart Failure, Hypertension, Obesity, COPD, and Diabetes.
Complications
With regard to complications of Myocardial Infarction, there were
again similarities between the 1976 and 1979 studies.
The 1976
study reported 48.9 percent of the group had complications such as
Congestive Heart Failure, Cardiac Arrest, Arrhythmias, and Angina,
and 41.2 percent of the 1979 group reported the same complications.
Length of Stay
The average length of hospital stay for Myocardial Infarction
46
patients dropped two days between 1976 and 1979 (see Table 9).
was a
one~day
There
drop in patient days for both the Cardiac Care Unit
(CCU) and on the Medical Floor.
Table 9
Length of (Hospital) Stay
1976
1978
1979
Range
(Days)
X./lof
Days
Range
(Days)
X.I! of
Days
Range
(Days)
5.1
n/a
5.4
n/a
4.1
2-7
8.8
n/a
7.9
n/a
7.3
3-13
jALos 13.9
n/a
13.2
n/a
11.3
6-20
XI! of
Days
ccu
~ed.
Flr.
Tota
n/a=not available
The 1976 average CCU stay was 5.1
day~
and Medical Floor stay was
13.9 days; but, in 1979, the average lengths of stay were 4.1 days
(CCU) and 11.3 days (Medical Floor).
In 1979, the total days of
stay ranged from 6 - 20 days, the CCU stay ranged from 2-7 days,
and the Medical Floor stay ranged from 3 - 13 days.
With regard to
month of discharge, patients were most frequently discharged in
October (six patients), January or May (five patients each).
Prior Admissions
For the 1979 st1-1dy, prior admissions were divided into two categories:
cardiac and non-cardiac.
The data available from the 1976 study re-
ported nine (19 percent) of the patients with one or more previous
admissions for a cardiac problem.
In 1979, admissions increased to
ten (29.4 percent) patients who had one or more prior cardiac ad-
47
missions.
In fact, of the 1979 study group, five patients had one
previous cardiac admission each and five patients had a total of
16 prior admissions.
The most common diagnoses on prior cardiac ad-
missions were Coronary Artery Disease, Congestive Heart Failure, Cerebrovascular Accidents, and Hypertension.
When reviewing the previous admissions for non-cardiac conditions,
28 ( 82.4 percent) of the 19 79 patients had one or more prior admissions, 16 (47.1 percent) patients had one admission each and 12
(35.3 percent) had a total of 31 prior admissions.
The most fre-
quently reported prior admissions were for hernias, tonsillitis/adenoiditis and appendicitis.
Readmissions
Of those 34 patients discharged in 1979 with Myocardial Infarction,
11 (32.4 percent) had been readmitted for cardiac problems ranging
from further Myocardial Infarctions to Congestive Heart Failure to
Cardiac Catheterizations and Open Heart Surgery.
The 11 patients
who had cardiac readmits had a total of 18 readmissions.
The 1979
study group had few readmissions to date for non-cardiac problems.
Of the three patients who were readmitted, one had Diabetes-Out-OfControl, one had a Cholecystectomy, and one had a Skin Graft for
Cellulitis.
Risk Factors
For the 1979 study(;.· e_!g_ht risk factors were identified\ (see Table 10):
.,-
------.:-,
smoking, heredity, alcohol, obesity, stress, hypertension, rheumatic
heart disease, and prior history of cardiac disease.
The frequency
of each risk factor was calculated when they were identified and
48
recorded in patients' charts.
The most frequent risk factors were:
smoking, heredity, hypertension, and obesity.
Although the rank order
of these four risks varied by sex (refer to Table 10), they nonetheless remained the most common risks.
Male patients averaged more
risks per patient (2. 3) than female patients (1. 7).
The 1979
st~dy
group averaged 2.1 risks per patient.
Table 10
Risk Factors
II Males
w/Risk
Smoking
Heredity
Hypertension
Obesity
Prior History
Stress
Alcohol
Rheu.Hrt.Dis.
II Females
w/Risk
15
9
10
8
7
4
1
0
Totals
54
Average fl Risks 2.3
Total
w/Risk
5
6
2
2
1
0
1
2
20
15
12
10
8
4
2
2
19
1.7
73
2.1
.
An additional item of data which was retrieved in the 1979 study was
the extent to which the form "Cardiac Rehabilitation" was being
utilized by physicians to order rehabilitation activities.
lowing in a summary of the utilization:
The fol-
ten charts (29.4 percent)
did not contain the form; four charts (11.8 percent) did contain the
form but they were totally blank; 14 charts (41. 2 percent) had
partially completed forms; and, the remaining six charts (17.6 percent) had mostly completed forms.
The term "partially" complete for
the purpose of this study was defined as having one or two stages of
49
rehabilitation checked or having checkmarks in some of the left hand
columns.
"Mostly" completed forms were identified as those where
four stages were checked in the left hand column and some follow
through did seem to occur.
None of the charts contained a "Cardiac
Rehabilitation" form which was 100 percent completed.
CARDIAC TEACHING DATA RESULTS
It was noted during the 1979 study that physician awareness of the
cardiac patient teaching program was increasing as 12 (35.3 percent)
physicians had documented in their Discharge Summaries that patients
had received the cardiac education program.
However, even the 22
(64.7 percent) charts whose Discharge Summaries contained no
references to patient education had physician orders for the education program.
Only one of the 34 Myocardial Infarction patients had chart documentation that an educational needs assessment had been performed
before the teaching program commenced.
That particular needs
assessment was written on the Patient Education Teaching Checklist.
All of the charts contained a patient education form (i.e., Patient
Education Care Plan/Teaching Checklist), but only 21 (61.8 percent)
of these had comments in the "Special Physician Instructions" section.
Comments given by physicians were, for the most part, directly related to instructions for patient teaching.
Comments ranged from
brief statements such as "Stage III" or "Post-MI teaching" to more
lengthy and explanatory statements such as:
"Needs instruction and understanding of process
infarct and needs to slow down temporarily •.••
50
•• resume regular activities gradually ••. learn to
recognize angina •.• "
"Please educate re: MI recovery ••• may be a candidate
for angiography ••• needs also to understand the importance of weight loss. This patient needs to understand her disease sufficiently to make a decision re~
garding further work~up and surgery if indicated .•• "
In follow-up to the 1978 study, the number of 1979 teaching contacts
by team member were calculated (see Table 11).
The 1978 number of
total contacts per Myocardial Infarction patient averaged 9.7 and in
1979 it dropped slightly to an average of 8.3 contacts per patient.
Table 11.
Teaching Contacts and Documentation
·--·
//---
1978
Patients: N=21
1979
Patients: N=34
Documented Teaching
(Teaching
\ Contacts. . On Pt. Ed. Forn Contacts
\
N2
%2
N
X
' N:L X/
CCU NURSE
POST CCU NURSE
Documented
On Pt.Ed.Forn
N
%
5.4 3
63
1.9
63
100.0
.2
12
0.4':1:
9
75.0
DIETICIAN
1.6
47
1.4
15
31.9
OCCUP.TH.
0.9
01
3.0
20
19.8
PHYS.TH.
0.8
27
0.8
7
25.9
SOC.WORKER
0.8
27
0.8
0
-
277
8.3
114
PHARMACIST
TOTALS
-
9.7
-
-
41.2
:!..unknown
2 not available
3 not separated in 1978
4adjusted X as five patients did not
have take home meds
51
The differences between 1978 and 1979 occurred in two major areas.
First, the teaching by the CCU nurse appears to have decreased from
several contacts to zero.
Secondaly, the contacts by an occupational
therapist increased from an average of 0.9 to 3.0 per patient.
ther, when
~he
Fur-
teaching contacts were displayed by day of stay, they
appeared to group around the second through the fifth day of stay
on the Medical Floor.
The 1979 study also included retrieval of data regarding whether or
not the teaching contacts were documented on the patient education
form.
It was found that only 41.2 percent of the teaching contacts
(see Table 11) appeared on the Teaching Checklist.
10 percent of those contacts were not dated.
Approximately
The majority (58.8 per-
cent) of the teaching contacts were found on other forms in the
medical record (e.g., Diet, Progress Notes, or Occupational Therapy
Record).
From documentation in the 1979 charts (i.e., whether on the Patient
Education Care Plan/Teaching Checklist or other forms), it appeared
that almost all patients were taught:
Heart Anatomy/Physiology,
Pathophysiology, and Risk Factors (see Table 12).
None of the five
CCU modules were documented as being taught; however, with changes
in staffing in 1979, the Teaching Checklist was not put on a medical
record until after the patient was transferred to the Medical Floor.
This would not have provided an opportunity for the CCU Nurse who
had done some teaching to document on the Teaching Checklist.
How-
ever, comments regarding teaching were also absent in the Nursing
Notes for the CCU stay.
With regard to the post-CCU teaching modules,
52
the greatest number of omissions occurred with Sexuality, Angina,
Community Resources, and Atherosclerosis.
There were some instances
where the modules on Angina or Congestive Heart Failure were not
taught to patients with a history of that condition.
Table 12
Documentation of Teaching
Modules Omitted~ and Added 2
Module
1978
1979
II of Patients
(N = 21)
II of Patients
(N = 34)
f..
-14
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
11.
. . 12.
13.
-12
-15
-17
CCU Orientation
Sup. Services
CCU Diet
Patient Rept.
Transfr. Prep.
Heart Anat/Physio.
Pathophysiology
Angina
Post CCU Diet
Medication
A-B Exercise - Stress
C · Other Risks
Sexuality
Atherosclerosis
14. Commy. Resors.
Congestive Heart Fail.
Rheum. Heart Dis.
Open Heart Surgery
~
2
3
-34
-34
-34
-34
-34.
-14
- 1
- 2
- 3
- 2
-22
- 7
-13
- 3
- 5
-14
- 23
- 23
-10
-13
-16
-28
3
+ 4
- 7
- 4
-19
-29
3
3
+ 1
omissions are indicated with a minus sign
additions are indicated with a plus sign
not separated for the 1978 study
In the 1979 study, data was also collected to determine whether the
discharge instructions were included on the Patient Education Care
Plan/Teaching Checklist.
It was recognized that the form requests
"expected" discharge instructions from the physician and that actual
53
discharge instructions or documentation that discharge instructions
were given may be duplicated in other parts of the chart.
Of the 34
medical records in the 1979 study group, discharge instructions were
documented as follows:
31 in Physician Orders, 25 on the patient
education form, and 18 in Physician Progress Notes.
Only 12 charts
had documentation in the Nurses' Notes that discharge instructions
had been given.
Five patients (14.9 percent) had been given the post-teaching test
prior to discharge while 29 (85.3 percent) of the 1979 study group
had no post-test.
Of the five patients who were tested, three had
scored 100 percent, one had scored 96 percent, and.one had scored 88
percent.
None of the patient education forms for 1979 contained documentation
that an evaluation of the cardiac teaching program had occurred relative to teaching goals for the patient.
FINDINGS
Description of the Target Population
In summarizing the 1979 and 1978 surveys and then comparing that
data to the 1976 survey, it appeared that on an annual basis there
were approximately 35 Myocardial Infarction patients who directly
benefited from the Cardiac Teaching Program.
Additionally, patients
with other types of cardiac conditions (e.g., patients with Congestive
Heart Failure or Pacemakers) also received teaching.
54
When assessing the total 1979 population demographically, there
appears to be little change between the 1976, 1978 and 1979 Myocardial Infarction patient with the exception that more patients,
regardless of sex, were still employed.
As in 1976, both the 1978
and 1979 study groups had a wide range of occupations with no one
type of occupation being predominant.
Approximately two-thirds of
the population continued to be male and one-third female.
Profile of Male Patients
The male patients in the 1979 study generally can be described as
they were in the 1976 study.
They were an average age of 61 years,
English-speaking, employed, resided in the Ventura catchment area
and usually had a private medical provider.
Males were still pre-
dominantly Caucasian but there had been a substantial increase in
the number of males who were of Mexican-American descent.
Profile of Female Patients
The 1979 female patients, with an average age of 62 years, were,
overall, seven years younger than the 1976 female patients.
Al-
though most of the females were English-speaking Caucasians as in
the 1976 study, the number of females of Mexican-American descent
had doubled.
Almost all of the female patients were still employed
in some capacity outside the home, resided in the Ventura catchment
area, and usually had private medical providers.
Description of Medical Findings of Target Population
When the medical conditions of the 1979 study group were compared
to the two previous groups, there appeared to be a trend toward an
increase in the number of patients who had one or more other medical
55
problems; however, the types of other medical problems remained the
same (e.g., congestive heart failure, angina and various .types of
arrhythmias).
Mortality Rate
The mortality rate during hospital stays was zero.
Rate of Complications
The rate of complications during the hospital stay for Myocardial
Infarction remained, as in the previous studies, in the 40 percent
range and of the same causes.
Average Length of Stay (ALOS)
Interestingly, the average-length of hospital stay appeared to have
decreased by two days.
This represented a one-day drop in length of
stay in the Cardiac Care Unit as well as a one-day drop in length of
stay on the Medical Floor.
Prior Admissions
The number of patients who had previous cardiac admissions appeared
to be trending upward as almost one-third of the 1979 study group
reported prior cardiac problems compared to approximately one-fifth
of the 1976 study group.
A review of their prior cardiac admissions
or problems revealed the cardiac conditions to be of a progressive
type in which little could be done to totally stabilize the problem,
but, rather all one can dowould.be to treat and then try to control
the symptoms as they occurred.
The two most frequent non-cardiac admission problems were for
hernias, appendicitis, and, during childhood, tonsillitis.
56
Readmissions
The readmission rate for cardiac problems had not been established in
the 1976 study.
However, the 1978 study indicated that about ten
percent of the patients were readmitted for the same or similar cardiac problems.
In 1979, the readmission rate jumped to over 30 per-
cent of the group.
Risk Factors
The 1979 study initiated data collection with regard to eight risk
factors:
smoking, heredity, alcohol, obesity, stress, hypertension,
rheumatic heart disease, and prior cardiac history.
Although there
were differences in rank order by sex, the most frequent risks for
either sex were:
smoking, hypertension, obesity and heredity.
was an average of 2.1 risks per patient.
Description of the Findings of the Patient Education Care Plan/
Teaching Checklist Results
Teaching Contacts by Frequency and Day of Stay
The number of teaching contacts per patient per admission was eight
to nine.
stay.
There appeared to be zero teaching contacts during the CCU
Teaching contacts tended to occur most frequently around the
second through fifth day of stay on the Medical Floor.
Teaching Contacts by Team Members
Although the nurse educator continued to have the most contacts with
each patient, the frequency of teaching by the CCU nurse appeared to
decrease dramatically between 1978 and 1979.
Conversely, the invol-
vement of the Occupational Therapist appeared to triple between 1978
and 1979.
57
Modules Taught
When reviewing the documentation on which of the individual teaching
modules were or were not taught, the modules taught at least 90 percent of the time were:
factors.
were:
anatomy/physiology, pathophysiology and risk
Those modules taught less than 50 percent of the time
CCU modules, community resources, sexuality, angina and
atherosclerosis.
Discharge Instructions
Approximately 75 percent of the time physicians documented expected
discharge instructions on the patient education form.
Teaching Assessment
Pre-tests had not been performed.
Post-teaching tests had been
given to 15 percent of the patients.
Cardiac Rehabilitation Form
The Cardiac Rehabilitation form had been utilized for approximately
20 percent of the rehabilitating cardiac patients.
Physicians' Reference to Patient Education
Every chart surveyed contained a physician's order for the cardiac
teaching program.
Additionally, almost every chart had either a
direct reference to patient education in the Discharge Summary or
pertinent education instructions written on the Patient Education
Care Plan/Teaching Checklist.
This Chapter has presented results and findings of the 1979 study
of patient education and Myocardial Infarction patients.
In those
instances where the earlier studies of 1976 and 1978 had comparable
data, changes or similarities were noted or tables were displayed
58
with two or three years of data.
For those items which were first
collected with the 1979 study, only 1979 data were displayed or
listed in tables.
Chapter 5
CONCLUSIONS, RECOMMENDATIONS AND SUMMARY
The evaluation of GHVC's cardiac teaching program was based on
medical record data obtained fr.om Myocardial Infarction patients·
discharged in 1979.
The first segment of the study gathered demographic and medical
data.
These data were compared with data drawn from two similar
studies performed in l976 and 1978 in order to determine if the
target population had changed with regard to specifically identified
characteristics.
Those characteristics which changed could be
evaluated in terms of the need to make revisions to either teaching
content or program areas (e.g., objectives, methodology, teaching/
assessment).
The second part of the study gathered ·(for the first time) data
from the Patient Education Care Plan/Teaching Checklist (PECP).
The PECP was the form required in the medical record of patients
who were included in the cardiac patient education program.
The
PECP had been developed from the activities required in the education
program and provided a specific format in which each teaching team
member could concisely document patient education contacts and
activities (e.g., physicians' order/instructions, patients' needs
assessments, teaching module checklist, discharge planning, program
evaluation).
Data from the PECP could not be compared to earlier
studies but rather was compared to the patient education program
requirements as specified in the Cardiac Teaching Guide and outlined
59
60
by the PECP.
Areas where program requirements were not met could be
identified, assessed, and, where needed, modified or reintroduced to
team members.
Since this Investigator presented preliminary findings (including conclusions and recommendations) to the Director of Patient Education
and the cardiac teaching team members, several revisions were started
while this project was being finalized in written report form.
Therefore, in those areas where significant revisions had been
initiated, and in some instances completed, comments in the format .
of NOTES have been included for the reader's information.
This Chapter will present conclusions and recommendations regarding
the cardiac teaching program.
The Investigator's comments and obser-
vations will be utilized where data may not be sufficient to draw a
conclusion but where trends or "food for thought" types of items
present themselves.
CONCLUSIONS
Demographic Characteristics of the Target Population
The target population of the 1979 study had changed somewhat from
the 1976 and 1978 study groups in that:
(1)
there were a greater
number of females (although males continued to be the majority) and
these females were younger; (2) almost all of the patients, regard-,
less of sex, were still employed; and, (3) there was not only a
substantial increase in the number of Mexican-American patients but
also these patients were primarily Spanish-speaking patients.
61
Medical Characteristics of the Target Population
The cardiac condition of the current target population appeared to
be more chronic and complicated as evidenced by a sharp upward trend
in the number of prior cardiac admissions as well as number of cardiac
readmissions.
Additionally, with the 1979 study, there was an inves-
tigation of risk factors and the "average" cardiac patient had 2.1
risks.
It was interesting to note between 1976 and 1979 the average length
of stay had decreased by two days (i.e., a one-day drop in length of
stay on the CCU as well as a one-day drop in length of stay on the
Medical Ward).
Patient Education Practices as Compared to Cardiac Teaching Guide
Teaching Contacts and Modules
The number of teaching contacts by various team members did not, on
review of the data gathered from medical record documentation, appear
to be similar to that suggested by the Guide.
For example, there
were modules specifically for the patient during his/her CCU stay yet
there was no documentation of the CCU nurse(s) teaching these
modules.
Additionally, the physical therapist appeared to be involved
infrequently while the occupational therapist was a very active team
member.
After discussing the documentation regarding frequency with which
each team member was in contact with the cardiac patients, some of
the differences between apparent practices and Guide protocol were
attributed to lack of documentation.
However, other differences were
attributed to actual changes in participation by various team members.
62
For example, the increased involvement of the occupational therapist
was due to a change in occupational therapy staffing and an interest
on the part of the new occupational therapist to participate in the
teaching program.
On the other hand, physical therapy department
staffing had been cut to such an extent that patient education activities were limited to only those cardiac patients whose rehabilitation program required physical therapy.
While reviewing the modules taught to each patient as tabulated from
the Patient Education Care Plan/Teaching Checklist, the teaching
team was made aware that five of the 14 required modules were
taught less than 50 percent of the time.
Although the teaching
team also attributed the apparent failure to teach the CCU, atherosclerosis and angina modules to a lack of documentation, there were
two modules (i.e., sexuality and community resources) which were
infrequently taught.
The teaching team agreed the sexuality module
was infrequently taught as many of the team members were not comfortable with the subject area.
The community resource module was
apparently overlooked as most team members assumed the attending
physicians were providing this ·data during follow-up care.
Discharge Instructions
Although the objective was to have discharge instructions documented
100 percent of the time on the Patient Education Care Plan/Teaching
Checklist, this Investigator believes the 75 percent rate is quite
commendable.
63
Teaching Assessments
The lack of pre-teaching tests was not unusual in light of the physical and emotional state of the patient in the CCU; however, some level
of assessment should be made early in each patient's teaching program.
The infrequent use of post-teaching tests could not be attributed
solely to a lack of documentation by the team members.
cussion with the nurse educator, it was found that the
After dispo~t-teaching
·
test was often utilized as a tool for reviewing the teaching program
content and objectives with each patient rather than as an assessment
tool.
Physicians' References to Patient Education
The Patient Education Department appears to actively promote the
availability and benefits of patient education programs as evidenced
by 100 percent of the physicians ordering the cardiac education program.
The cardiac program seems to have become an integral part of
each Myocardial Infarction patient's hospital treatment and rehabilitation program.
RECOMMENDATIONS
Target Population Demographic Considerations
Because the target population appears to be trending toward people
who are younger and still employed, program content and objectives
should be assessed to make certain that they are appropriate (e.g.,
Are physical activity levels and objectives focusing on re-employment
rather than recreation or exercise which are more common to retirement?).
64
Additionally, due to the greater number of Spanish-speaking MexicanAmerican patients, issues specific to the Hispanic culture must be
considered (e.g., How to deal with the sexuality information; are
diet instructions appropriate; what is the bi-lingual ability of
teaching team members).
Target Population Medical Considerations
After evaluating the medical condition of the cardiac patients
involved in the GHVC teaching program, one becomes aware that most
of these patients had a history of chronic cardiac problems.
The
drop in average length of stay was due not to a -lessening of the
severity or chronicity but rather was consistent with general medical
(i.e., cardiac) care practice of discharging uncomplicated Myocardial
Infarction patients earlier to home rest and care.
It is recommended that future studies continue to evaluate the
general nature of the target population's cardiac condition (i.e.,
chronic vs acute) by studying the rates of admissions and readmissions
as well as risk factors.
If the cardiac condition continues to be
chronic, the cardiac team would more than likely place greater
emphasis on behaviorally-oriented objectives rather than early prevention techniques and knowledge-level objectives.
It is further noted that the most common risk factors (i.e., smoking,
hypertension and obesity) can be controlled or even eliminated
\//
through patient compliance with healthy lifestyle habits taught in
the cardiac care program.
Even though data on risks (e.g., stress)
may be difficult to assess, future studies should continue to try
to obtain risk factor data.
The greater the awareness of these
65
...
~
.............~""/''
risks by physicians and patient educators, the greater the likelihood
the risks will be better documented and, thereby, included when
planning for patients' teaching objectives.
Patient Education:
Practices vs Guide
Over half of the teaching contacts (i.e., number of contacts and
modules taught) were not documented.
This is an important oversight.
It is recommended that the Director of Patient Education and the
teaching team discuss ways to develop better methods of monitoring
and documentation.
With regard to the teaching team being uncomfortable with the
sexuality module, it was suggested that an in-service education
session be included on a future team meeting agenda.
(NOTE:
The
teaching team did discuss the sexuality module at a team meeting
and, subsequently, initiated a four-session in-service education
program for themselves.)
Although each patient usually received follow-up care from his/her
attending physician, it was recommended that the community resource
module not be excluded and, in fact, that community cardiac resource information be gathered and, in some fashion (e.g., a
brochure), made available to each patient involved in the cardiac
teaching program.
Discharge Instructions
Physicians should continue to be reminded to write expected discharge instructions as early in each patient's stay as possible.
Physicians' assessments, expectations, and recommendations assist
the teaching team in preparing patients for post-discharge care.
66
Teaching Assessments
As early as possible in each patient's hospital stay, a teaching
assessment should be made and documented.
Not only will this help
to focus on areas of need for the individual patient, it will also
provide some baseline with which to compare any post-teaching assessment.
The post-teaching tests and surveys should be implemented as assessment tools rather than resources for review.
All test results
should be recorded.
Physicians' Awareness of Patient Education
The Patient Education Department should be commended on its active
promotion in the hospital as evidenced by the fact that every cardiac
patient was referred by physicians for patient education teaching.
The only recommendation in this area would be for the promotion to
continue.
OBSERVATIONS AND SUMMARY
The evaluation of GHVC's cardiac education program as described in
the preceding chapters identified areas which need modification as
well as areas of strength.
The cardiac patient population had changed demographically between
1976 and 1979 in that more of the patients were still employed,
there was an increase in the number of females as well as a decrease
in the average female's age, and a substantial increase in the
number of Spanish-speaking Hispanic patients.
From a medical stand-
point, the cardiac condition of the 1979 target population appeared
67
to be more chronic as evidenced by a rise in the number of both prior
cardiac admissions and post-discharge readmissions.
Also, the car-
diac patients, on the average, had 2.1 risks.
With regard to the cardiac patient education program, the lack of
documentation appears to be the major problem area.
In an effort to
encourage documentation, particularly on the Patient Education Care
Plan/Teaching Checklist, several revisions to the form were suggested
to the Director of Patient Education.
These revisions related to
format as well as to adding a checklist type of section for the
teaching modules so each could easily be marked after it was taught.
In addition to the multiple information discussions (which occur in
the office, hallways, and on the wards) between team members, a
regular team meeting might be beneficial.
Whether the meeting is
weekly or monthly, patient assessments, program assessments,
in-service education needs, or any other topics which team members
might suggest could be discussed.
The Patient Education Department and cardiac teaching team members
are all actively involved in promoting the benefits of patient
education.
Patient education appears to have become an integral
part of each cardiac patient's rehabilitation program as every
medical record reviewed had a physician order for patient education, and, almost half of the Discharge Summaries included references
to patient involvement in the cardiac education program.
SELECTED BIBLIOGRAPHY
68
69
SELECTED BIBLIOGRAPHY
American Heart Association.
005-D.
Heart Facts 1980, 1979, Pamphlet 55-
American Heart Association.
005-E.
Heart Facts 1981, 1980, Pamphlet 55-
American Hospital Association.
Chicago, Ill., 1965.
Health Education in the Hospital,
American Hospital Association Center for Health Promotion.
ing Inpatient Education Activities, Chicago, 1978.
Financ-
American Hospital Association. Hospital Inpatient Education: Survey
Findings and Analysis, 1978, U. S. Dept. of Health and Human
Services, Atlanta, Georgia, 1980.
Barger, Robert C. and Jan Barger. Pharmacist, Nurse Cooperate in
Taking Drug Histories. Hospitals, Vol. 50, September 1, 1976:
93-94.
Berger, B. and J. Hopp, V. Raettig. Values Clarification and the
Cardiac Patient. Health Education Monographs, Vol. 3, No. 2,
Summer 1975: 191-199.
Bille, D. The Role of Body Image in Patient Compliance and Education.
Heart and Lung, Vol. 6, .No. 1, January-February, 1977: 143-148.
Brody, D. Feedback From Patients As A Means Of Teaching Nontechnological Aspects of Medical Care. Journal of Medical Education, Vol.
55, No. 1, January 1980: 34-41.
Clark, C.M. and E.W. Bayley. Evaluation of the Use of Programmed
Instruction for Patients Maintained on Warfarin Therapy. American
Journal of Public Health, Vol. 62, No. 8, August 1972: 1135-1139.
Colling, A. et al. Tesside Coronary Survey: An Epidemiological
Study of Acute Attacks of Myocardial Infarction. British Medical
Journal, Vol. 2, November 13, 1976: 1169-1172.
Covington, T. R. and F. G. Pfeifer. The Pharmacist--Acquired Medication History. American Journal of Hospital Pharmacy, Vol. 28,
January 1971: 49-53.
Craddock, J. C. and G. R. Whitfield, J. W. Menzie and C. L. Fortner.
Postadmission Drug and Allergy Histories Recorded by a Pharmacist.
American Journal of Hospital Pharmacy, Vol. 29, March 1972: 250252.
70
Crawshaw, J. E. Community Rehabilitation After Acute Myocardial
Infarction. Heart and Lung, Vol. 3, No. 2, March-April 1974:
258-262.
D'Altroy, L. et al. Patient Drug Self-Administration Improves
Regimen Compliance. Hospitals, Vol. 52, November 1, 1978: 131136.
DeBerry, P. Teaching Cardiac Patients To Manage Medications. American Journal of Nursing, Vol. 75, No. 12, December 1975: 2191-2193.
Douglas, J. E. and T. D. Wilkes. Reconditioning Cardiac Patients.
American Journal of Family Practice, Vol. 11, No. 1, January 1975:
123-129.
Forbes, W. H. Longevity and Medical Costs.
Medicine, Vol. 277, July 1967: 71-78.
New England Journal of
Fralic, M. F. Developing a Viable Inpatient Education Program-A
Nursing Administration. Journal of Nursing Administration, Sept~
ember 1976: 30-36.
Green, Lawrence et al. Health Education Planning: A Diagnostic
Approach, Mayfield Publish~ng Co., Palo Alto, 1980.
Green, Lawrence and D. Levine. Health Education for Hypertensive
Patients. Journal of the American Medical Association, Vol. 241,
No. 16, April 20, 1976: 1700-1703.
Huff, Robert M. Health Education in a Clinical Setting: A Pilot
Study in Myocardial Infarction Patient Education. M.P.H. Graduate
Project. California State University, Northridge, May 1974.
Inui, Thomas et al. Improved Outcomes in Hypertension After Physician
Tutorials. Annals of Internal Medicine, Vol. 84, No. 6, June 1976:
646-651.
Kaye, Ronald and Ann Hammond. Understanding Rheumatoid Arthritis.
Journal of the American Medical Association, Vol. 239, No. 23,
June 9, 1978: 2466-2467.
Kelsey, Helen and Virginia Beamer. A Post-Hospital Health EduGation
Program •. Heart and Lung, Vol. 2, No. 4, July-August 1973: 512-514.
Lazes, Peter. Health Education Project Guides Outpatients to Active
Self-Care. Hospitals, Vol. 51, February 16, 1977: 81-86.
Linde, B. and N. Janz. Effect of a Teaching Program on Knowledge and
Compliance of Cardiac Patients. Nursing Research, Vol. 28, No. 5,
September-October 1979: 282-286.
71
Logan, Katherine. National Agency To Be Health Education Troubleshooter. Hospitals, Vol. 50, May 1, 1976: 69-71.
Redman, Barbara K. Client Education Therapy in Treatment and Prevention of Cardiovascular Diseases. Cardiovascular Nursing, Vol.
10, No. 1, January-February 1974: 1-6.
Romero, Patricia. Preoperative Teaching for Cardiovascular Surgical
Patients. Cardiovascular Nursing, Vol. 14, No. 6, NovemberDecember 1978: 27-32.
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1971: 793-802.
Rosenberg, Stanley G. and Beatrice Judkins. Federal Programs Make
Education An Integral Part of Patient Care. Hospitals, Vol. 50,
May 1, 1976: 62-65.
Rossel, Carol and Irene Alyn. Living With A Permanent Cardiac Pacemaker. Heart and Lung, Vol. 6, No. 2, March-April 1977: 273-279.
Sackett, David L. et al. Randomized Clinical Trial of Strategies
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.
Patient. Cardiovascular
Nursing, Vol. 15, No. 4, July-August 1979:
16-21.
Somers, Anne R. Consumer Health Education:
Hospitals, Vol. 50, May 1, 1976: 52-56.
To Know Or To Die.
Toth, Jean. Effect of Structured Preparation for Transfer on Patient
Anxiety on Leaving Coronary Care Unit. Nursing Research, Vol. 29,
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/
APPENDIXES
, II
71
Audit Date:
Auditor's Initials:
CARDIAC TEACHING PROGRAM WORKSHEET
1979 DISCHARGES
DEMOGRAPHIC:
1. Chart
4. Ethnicity:
MEDICAL:
2. Sex:
1. Age: ___
Male
Female
Caucasian
Mex/Amer
--
Black
Other
Specify:
N/A
10. Date of:
12. Expired:
Admission _ _ __
__Yes
No
11. Discharge _____
13. Indicate Primary Discharge Diagnosis:
_ Myocardial Infarction
__ Angina
Congestive Heart
--Cardiomyopathy (Type:
-- Other (Specify:
5. Occupation------- 6. City of
Pacemak~r
--
)
)
Residence
14. # of Days Hospitalized in CCU
15. # of Days Hospitalized in Med. Floor
English
s·panish
Other (Specify:
7. Primary Language:
16. Complications of M. I. (if any)
8. Usual Medical Provider:
Private Medical Doctor
Other (Specify:
Hospital Outpt. Clinic
17.111 of Prior Admissions for Cardiac Problems:
17.2 LOS of Each
17.3 Final Diagnosis of Each
18.1# of Prior Admission for Non-Cardiac Problems:
18.2 LOS of Each:
18.3 Final Diagnosis of Each - - - - - - - - - - - -
9. Comments:
Rheum.F:lrt, Prtor Mist.
NQne; -gmokin~; ~eredity;
28. Ri%f coFficiors:
o ·
Ohgs1ty
--tress,
~perten
27. Cardiac Rehab Form:
Not on Chart
On chart but not complete
On chart;complete
26. Was Pt.Ed. mentioned in Dis.Summary:
Yes
No
19.1 # of Cardiac Problem Readmissions After Discharge:
19.2 LOS of Each:
19.3 Final Diagnosis of Each
---------20.1 # of Non-Cardiac Problem Readmissions After Discharge:
20.2 LOS of Each:
20.3 Final Diagnosis-Df Each
'd:t>
"'"'
OQ'O
Ill "
...."><
>-'0-
0
H>
N
:t>
-....J
N
73
Appendix A
Page 2 of 2
CARDIAC TEACHING PROGRAM WORKSHEET
1979 DISCHARGES
21.
Educational Needs Assessment Performed?
If "yes," where?
Yes
Dr's Orders
No
NursingNotes
=Teaching Checklist= O t h e r : - - - - - - - - - - - 22.
"Patient Education Care Plan" form in chart?
Yes
No
22.1 Are "Special Physician Instructions" completed?
Yes
No
(List Instructions: ~~-~-~~-~--------------)
22.2 Documentation of Teaching Checklist*
Day of Stay (DOS)
1
Module
2
3
4
5
6
8
9 10 11 12 13 14 15 .....
CCU Orientation
Supportive Care
CCU Diet
Patient Reporting - - - - - - - - - - - - - - - - - - - - - - - - - - Transfer Prep
Heart A & P
Pathophysiology
Angina
Diet Post CCU
Drug Management
Risks: Stress
Exercise
All Others
Sexuality
Atherosclerosis
Comm.
Resources
Other: (Specify)
*Indicate who taught each module and on which DOS; use the following
symbols: CN=CCU Nurse, PN=Post-CCU Nurse, D=Dietician, OT=Occupational Therapist, PT=Physical Therapist, P=Pharmacist, O=Other(specify)
22.3
23.
Was Teaching Checklist complete?
(Specify additions/ommissions:
Yes
Where were discharge instructions documented:
Pt. Educ. Care Plan Form
Nursing Notes
24.
Post-Test Given:
25.
Was Evaluation of Teaching Documented?
Yes
No
Dr's Orders
Other (Specify:
No
By Whom (Specify) _____________
Yes
No
Comments - - - - - - - - - - - - - - - - - - - -
74
Appendix B
Page 1 of 2
MA.IOfl MEDICAL PROBLEMS:
1. ________ _
3. · - - - - - - - - - - - - - - · - ·
2. · · - - · - - - - - - - - - - -
4. - - - · · · - - - · - - - - - -
PATIENT EDUCATION NEED (Checil Desired Program):
D
0
0
Myocardinl Infarction
D P.T.
*D O.T.
Anr.inn
CIIF
D
D
P.acemakcr
D
Rheumatic Heart Disease
Cardiomyopathy (Spedf.y)
D
D
D
D
D
D
D
D
Hypertension
Diabetes
Prenatal
Infant Care
Family Planning
Diet
Medications
Mental Health
0
Videotape Programs
0 Diabetic Series
D
0
Prenatal Series
Infant Care
Death and Dying
Cardiac Series
Pre/Post Operative Teaching
Other ( S p e c i f y ) - - - - - - - -
0
0
0
0
----·-·-----·---.
:qyi;t'/.1 ~~ ...derh;,g/1/.i.
Prn..(rum {lh:o c..?Jcs:_}t 0.1'. and P. T. and tpeci{y activity /cvds u;;d.er special illstructions.
[JJ·.r-:.~~i.'J.~ i·J~).::nclt,N lt·~~1'.11.UC1'IOJ'\S: -----~------------------------------------------------
./\PPr:..OXJ:~·l~\.1:{i; DATi~
(}f.
PATIENT DrSCHARCE: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
~;XPECTF:D DISCH A ltGE MEDlC.AT\ONS: ----------------·-------·-·-··----- ·--- - - · · -----·
EXFEC'.fi~D iJlSCHl'.. T!.Cf~ lJl~T: --~ ----~------------------~------------------------- ------·---·-
i'IIYSICIAN SIGNATURE: ·····----------------·--------------
I'JI.TIFNT F.DU:::i:(f!Oi'l Ci\1·\E PLAN
GnJERAL HOSPiTJI.L VENTURI\ COUNTY
PATIENT EDUC/,TION PHOJECT
DATE: - - - · - · · - - - - - - - - - - - - -
75
TEhGH!NG CHECKLiST
Appendix B
(/'LEASE /.UTE AND JNITJAL TEACHING AS COMPLETEDJage 2 of 2
·t. BI\S!C C!\KDIAC f'ROGB.l\i'/1
_] Orientation to CCli . ........ : . ..... .
2. DIABETES
D
Insulin Admin .................... .
C"J Supportive Care . . . . . . . . . . . . . . . . . . . .
D
Urine Testing..................... .
[--, J.lic•l in CCU ...................... .
D
Hyper/Hypoglycemia .............. .
r.:..J
P.at<ont. Report:ing ................. .
D
!':tio!ogy ........................ .
CJ 'l'ransfl•r Prep ..................... .
0
Diet............................. .
[_] Heart A 6·. P ...................... .
r::J
Exercise ......................... .
D
Pati:opbydo!ogy .................. .
D
Side Day /Tr~vcl. .................. .
D
i\J!p:in:o." ... . . . . . . . . . . . . . . . . . . . . . . .
D
Fo••t Care ....................... .
[.] Diet (l'o•t CCU) .................. .
D
Personal Hygiene .................. .
D
Otlwr: ----------·------·--·
D
Basic Infant Care .................. .
0
l\1edicaliuw: .......... ............ .
D
Ri:.i\ F:-!.etor~ . . . . . . . . . . . . . . . . . . . . . .
c:-:r
s·'.''""tit}· ........................ .
3. INFNH C/.RE PAllli•!T Ei..'!JGXfiO'<
[_) em' ........ .
D
Infant Nutrition . , ................ .
...................... .
D
Preventive Health ~1euwres .......... .
Cl Gudi'ln:ynpnlby . . . . . . . . . . . . . . . . . . .
D
Community/Agency H.csourc~~s ....... .
CJ Hl!ll ........................... .
J
Pi~'~':mai<C?i .
4. PRENATAL CARE
D
l'hysicnl
Complaints ..
D
P.P. Care/Family Planning ........... .
r:-J
t\ulriU:m, ],;x,erc;se., Meds, Hyeicac .....
0
Dasic Infont. Car~/Signs or Jlhu-~s . ..... .
[J A t~li..t P ni rn.·:~nan;,;y . . . . . . . . . . . . . . .
D
Infant i•intrit'on .................. .
[),_.:;,·<'• ;• ........· •........
D
Pr•..!V. He:"!.Eh j\1e~;.sur,'s/Ccm ltn~ot:..rccs ..
C:han;~es{C:ommon
[:J La\;uc ""''
5. OTI-iER TEACH lNG (Please Specify)
c_-:]
0 -·----·--I::::J
Cl
INS1'RUCTOI~
COMMEI\ITS: