Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project.

JBI Database of Systematic Reviews & Implementation Reports

2016;14(2):322-336

Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project

Yu Chen1,3 Li Zhu 2 Fei Xu 2 Jun Chen2

1. School of Nursing, Fudan University, Shanghai, P.R. China 2. Zhongshan Hospital, Shanghai, P.R. China 3. The Fudan Evidence Based Nursing Center: an Affiliate Center of the Joanna Briggs Institute, Shanghai, P.R. China

Corresponding author: Yu Chen [email protected]

Key dates Commencement date: March 2015 Completion date:

August 2015

Executive summary Background Heart failure is a major public health concern which contributes significantly to rising healthcare costs. Comprehensive discharge planning can improve health outcomes and reduce readmission rates which, in turn, can lead to cost savings. Objectives The aim of this project was to promote best practice in the discharge planning of heart failure patients admitted in the coronary care unit of Zhongshan Hospital. Methods A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool. Five audit criteria that represent best practice recommendations for heart failure discharge planning were used. A baseline audit was conducted followed by the

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implementation of multiple strategies, and the project was finalized with a follow-up audit to determine change in practice. Results Improvements in practice were observed for all five criteria. The most significant improvements were in the following: completion of a discharge checklist (from 0% to 100% compliance), comprehensive (i.e. inclusion of six topics for self-care) discharge education for patients (from 7% to 100% compliance), and conducting a telephone follow-up (from 0% to 76% compliance). The compliance rates for the two remaining criteria, completion of a structured education for patients and scheduling an outpatient clinic visit, both increased from 93% to 100%.Strategies that were implemented to achieve change in practice included development of a local discharge planning checklist, provision of training for nurses, and development of resources. Conclusions The project demonstrated positive changes in the discharge planning practices of nurses in the coronary care unit of Zhongshan Hospital. A formalized discharge planning is currently in place and plans for sustaining practice change are underway. A continuous cycle of audit and re-audit will need to be carried out in the future to determine the impact of this evidence implementation activity on heart failure patient outcomes. Keywords heart failure; discharge planning; evidence-based practice; best practice; clinical audit

Background Heart failure (HF) is a complex clinical syndrome that results from structural or functional impairment of ventricular filling or rejection of blood.1 Dyspnea, fatigue and fluid retention are the major manifestations which may limit exercise tolerance, and lead to pulmonary and/or splanchnic congestion and/or peripheral edema.1 Many different methods have been utilized to categorize HF among which the New York Heart Association (NYHA) functional classification is widely used. The NYHA class focuses on exercise capacity and the symptomatic status of the disease, and categorizes HF into four classes: Classes I to IV. Another widely used categorization was introduced by the American College of Cardiology Foundation/American Heart Association (ACCF/AHA), which emphasized the development and progression of disease and classified HF into four stages: stages A to D. 1 Despite therapeutic advances, HF is a major public health concern of increasing relevance. In the United States (US), the lifetime risk of developing HF is 20% for people aged 40 years and over. 2 The prevalence ranges from 2% to more than 8%, depending on age.3 There is little data documenting the epidemiology of HF in China. The estimated prevalence is 0.9% which is lower than that reported in many Western countries (1.2% to 2.0%).4 In the US, the absolute mortality rate for HF is 50% within five years of diagnosis. 5 In addition, HF is a common cause for hospital admission and readmission with 83% of patients hospitalized at least once and 43% hospitalized at least four times. 6-8 The significantly decreased quality of life (QoL), especially in the areas of physical functioning and vitality, is a powerful predictor of hospital readmission.9,10 Because of the high medical resources incurred, HF is the most costly cardiovascular disease in the US.11 The total cost of HF care exceeds $40 billion annually with half of these costs spent on hospitalization.1

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Discharge planning is a process used to decide what a patient needs for a smooth move from one level of care to another, which can be completed by a doctor, social worker, nurse, case manager or other person.12 Discharge planning is an essential component of diseases management program. Generally, the basics of a discharge planning include evaluation of the patient by qualified personnel, discussion with the patient or his/her caregivers, planning for homecoming or transfer to another care facility, determining if caregiver training or other support is needed, referrals to a home care agency and/or appropriate support organizations in the community, and arranging for follow-up appointments or tests.12 Phillips et al. conducted a meta-analysis to evaluate the effects of comprehensive discharge planning plus post-discharge support on patients with HF.13 The results showed that comprehensive discharge planning with post-discharge support significantly reduced readmission rates and might improve health outcomes such as survival and QoL without increasing the cost of medical care. Vinson et al. reported that inadequate discharge planning was one of the leading factors associated with the readmission of HF patients within 90 days of discharge.14 Patients did not know how to follow their doctors’ advice regarding diet, exercise, self-monitoring and medication, which contributed to more than one third of them being readmitted.15 To facilitate the transition from inpatient to outpatient management, a focused, comprehensive, multidisciplinary discharge planning should begin upon patient admission and at multiple times during hospitalization.16 For patients with HF, this can be a particularly vulnerable period because of the progressive nature of the condition, complex medical treatments, various comorbidities and the multiple health practitioners who may have been involved in their management. 1 The literature highlights the importance of providing education and clear instructions to patients and their family members or caregivers as essential components of discharge planning. 1 Patient education should cover discharge medications (e.g. medicine list, dose, potential side effects, compliance strategies, cost issues), dietary recommendations (e.g. sodium restriction, fluid restriction, alcohol restriction), weight monitoring and management, activity level, social support, follow-up appointments and what to do if symptoms worsen.15 Facilitating smooth and safe discharge extends beyond patient education. It should also include providing post-discharge support to minimize gaps in understanding care plans and reinforce adherence to medications and follow-up services. Post-discharge support can be delivered through a home visit within seven to 14 days and/or a structured telephone follow-up within three days of hospital discharge.1 The AHA and the Heart Failure Society of America, as part of their commitment to improve the delivery of evidence-based care for HF patients, have developed a Heart Failure Discharge Checklist17 to assist with the discharge planning process. The checklist covers information related to medications, counselling and follow-up services which are all important components of transitional care.17 With the increasing incidence of, and readmissions associated with, HF, it is critical to implement thorough and comprehensive discharge planning for these patients. In China, however, discharge planning is not conducted in accordance with the best available evidence from research. Therefore, an evidence implementation project was undertaken to promote evidence-based discharge planning in HF patients admitted at the coronary care unit (CCU) of Zhongshan Hospital. The Zhongshan Hospital is a major teaching hospital affiliated with Fudan University. It has nearly 1200 HF admissions every year. Using the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES), a clinical audit was undertaken. Clinical audit is a process that seeks to improve the quality of healthcare by examining care practices against agreed standards or best practice recommendations, and

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changing practice when this is indicated.18 It helps determine whether there is a gap between “ideal” practice (what should be) and “actual” practice (what is real), which could then be a stimulus for change. A number of studies that used the clinical audit and feedback approach found this method effective for ensuring that nurses’ practices were compliant with best practice guidelines. 19,20

Aim and objectives The aim of this evidence implementation project was to promote evidence-based discharge planning for HF patients in the CCU of Zhongshan Hospital, with a view to improving patient outcomes and resource utilization. The specific objectives were: 

To improve current compliance with evidence-based recommendations regarding discharge planning for HF patients.



To increase nursing staff’s knowledge and skills regarding discharge planning for HF patients.



To formalize local practice in the discharge planning for HF patients.

Methods This project used the JBI-PACES and Getting Research into Practice (GRiP) audit and feedback tool. The JBI-PACES and GRiP framework for promoting evidence-based health care involves three phases of activity: 1. Establishing a team for the project and undertaking a baseline audit based on criteria informed by the evidence. 2. Reflecting on the results of the baseline audit, and designing and implementing strategies to address non-compliance found in the baseline audit, informed by the GRiP framework. 3. Conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and to identify future practice issues to be addressed in subsequent audits.

The project was registered as a quality improvement activity within the hospital, and therefore did not require ethical approval.

Phase 1: Team establishment and baseline audit The project team, consisting of a lecturer and registered nurses, was established. The team members, their positions, organizations and roles are presented in Table 1. The audit criteria were developed based on best practice recommendations for discharge planning as described in the Background section. A team meeting was conducted to familiarize the members with the project, and to discuss the audit criteria and data collection methods. In addition, the head nurse informed all CCU nurses about the project to facilitate efficient implementation. The baseline audit was conducted from March15 to May4, 2015.

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Table 1: Project team

Team member

Position

Organization

Role

Yu Chen

Lecturer

School of Nursing,

Project coordinator, protocol writing,

Fudan University

project design, process control and promote, questionnaire design, nurses training, data analysis and report writing

Li Zhu

Head

nurse,

Zhongshan Hospital

registered nurse

Communication nurses

with

training

other

nurses,

strategy

design,

supervision and data collection Fei Xu

Registered

Zhongshan Hospital

nurse Jun Chen

Registered nurse

Education implementation, supervision and data collection

Zhongshan Hospital

Education implementation, supervision and data collection

Table 2 shows the evidence informed audit criteria along with a description of the sample and the approach used to measure compliance with best practice for each criterion. Nursing records for 30 patients were reviewed for criteria 1, 2 and 4, while data for criteria 3 and 5 were obtained through interviews with nurses.

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Table 2: Audit criteria, sample and approach to measuring compliance with best practice Audit criterion

Sample

Method used to measure % compliance with best practice

1. A discharge criteria checklist is completed and documented.

Baseline: 30 HF patients who

To check nursing records.

were admitted to the CCU and prepared to discharge. Follow-up: 21 patients.

2. The patient has completed a


structured education prior to

were admitted to the CCU

discharge.

and prepared to discharge.


Follow-up: 21 patients. 3. The discharge education


includes diet, discharge


medications, activity level,


follow-up appointments, daily weight monitoring, and what

To interview nurses.

Follow-up: 21 patients.

to do if symptoms worsen. 4. An outpatient clinic visit is


scheduled for the patient


prior to discharge.



Follow-up: 21 patients. 5. A telephone or home visit is


conducted to reinforce

had been discharged from the

self-care instructions.

CCU.

To interview nurses.

Follow-up: 21 patients.

Phase 2: Design and implementation of strategies to improve practice (GRiP) Phase 2 was conducted from May 5 to July 12, 2015. In this phase, the project team reflected on the results of the baseline audit and summarized areas of excellent (over 75%), moderate (50%-75%) and low (less than 50%) performance. Guided by the GRIP framework, they brainstormed barriers to best practice delivery, identified strategies and resources to overcome the barriers, and implemented strategies identified as feasible.

Phase 3: Follow-up audit post implementation of change strategy The follow-up audit was conducted between July 13 and August 7, using the same evidence-based audit criteria and data collection process as the baseline audit. Out of the initial 30 patients, only 21 patients were involved.

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Results Phase 1: Baseline audit As shown in Figure 1, most patients had been provided a structured education (93%) and were given a schedule for an outpatient clinic visit (93%) prior to discharge. The compliance rate for the third criterion, (discharge education about diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and what to do if symptoms worsen) was only 7%. The compliance rates were lowest for the first and fifth criteria (0%).

Figure 1: Compliance with best practice audit criteria in baseline audit (%)

Phase 2: Strategies for Getting Research into Practice (GRiP) Four barriers to compliance with best practice were identified, and strategies to overcoming these barriers (as summarized in Table 2) were then implemented. Barrier 1: Nurses lacked knowledge on discharge planning for HF patients. 

Strategy: A training program, including a seminar, a practice demonstration and supervised practice, was implemented. All nurses in the CCU received this program. The seminar was conducted by the project coordinator who explained the project, emphasized the importance of discharge planning for HF patients, and discussed in detail the recommended practice for discharge planning in HF patients. At the end of the seminar, all nurses were required to complete a written examination (Appendix I) to evaluate their knowledge of discharge planning for HF patients. In addition, a senior nurse in the project team ran a practice demonstration on how to educate patients. Afterwards, nurses were asked to practice while being supervised by the senior nurse. Nurses had to pass the written examination and supervised practice before they were allowed to conduct discharge planning. A questionnaire for patients (Appendix II) was also developed to assess their understanding of the discharge education provided by the nurses. The questionnaire included 28 questions which focused on the six topics (i.e. diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and strategies for symptoms worsening) that should be covered in a discharge education.



Resources: The project coordinator developed educational slides, conducted the seminar, and provided written educational materials to nurses. A senior nurse held a simulation to demonstrate proper patient education. A handout which outlines instructions for patients (Appendix III) was designed to supplement the training. The project team also developed an

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examination paper to assess nurses’ knowledge on HF and discharge planning. A questionnaire for patients was also developed. 

Outcomes: All nurses were qualified to conduct discharge planning.

Barrier 2: Absence of a Chinese HF discharge checklist. 

Strategy: The English version of a HF discharge checklist, 17 developed by the American Heart Association and the Heart Failure Society of America, was translated by the project coordinator into Chinese using Brislin’s translation model.21 It was also adapted to Zhongshan Hospital’s current situation. The items “HF interactive workbook” and “Clinical summary and patient education record faxed to appropriate physicians” were deleted as they were not applicable in China. The project team discussed the feasibility and applicability of the checklist.



Resources: The Chinese version of a HF discharge checklist was developed (Appendix IV). A seminar (as reported above) was conducted to train the nurses on how to use the checklist.



Outcomes: The Chinese version of a HF discharge checklist was developed. All nurses were able to complete the checklist prior to patient discharge, with appropriate documentation in the nursing records.

Barrier 3: Formalized discharge planning increased nurses’ workload. 

Strategy: A worksheet, which outlines best practice recommendations, was developed to facilitate work flow for discharge planning (Appendix V). Nurses used the worksheet as a guide, which allowed them to monitor which recommendations had been or had not been achieved. An additional handout describing what should be considered in patient education was designed. Two posters (Appendix VI) were produced to display on the walls to educate HF patients about self-care.



Resources: A worksheet, a handout and two posters were designed to decrease nurses’ workload.



Outcomes: All nurses could conduct the formalized discharge planning as expected.

Barrier 4: Nurses lacked motivation to make a phone call to reinforce self-care instructions. 

Strategy: The importance of patient follow-up was emphasized during the seminar. Two senior nurses were assigned to conduct the telephone follow-up. An outline of what should be covered in the telephone conversation (i.e. weight management, monitoring of worsening symptoms and self-care instructions) was developed to serve as a guide and ensure that no information was missed (Appendix VII). In addition, the head nurse continuously monitored whether telephone support was received by discharged patients.



Resources: Two senior nurses were assigned to provide the follow-up support. The outline of phone call was made. The head nurse’s monitoring prompted nurses to provide telephone support.



Outcomes: The number of patients who received telephone follow-up, as reported by the assigned nurses, partly increased.

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Table 2: GRiP matrix Barrier

Strategy

Resources

Outcomes

Nurses lacked

-- Implemented a training

-- Educational slides

-- All nurses were

knowledge on

program.

discharge planning



Seminar

materials



Practice demonstration

-- Simulation

for HF patients.

-- Written educational

-- Setup qualification

-- Handout of

assessment.

discharge instruction



Written examination

-- Examination



Practice supervision

-- Questionnaire

qualified to conduct discharge planning.

-- Assessed the impact of patient discharge education. 

Questionnaire for patients.

Absence of a

--Developed a Chinese

--The Chinese

All the nurses were

Chinese HF

version of HF discharge

version of HF

able to complete the

discharge checklist.

checklist.

discharge checklist

checklist prior to

--Trained the nurses to use

--Seminar

patients’ discharge.

the checklist. Formalized discharge

--Developed a worksheet to

planning increased

optimize work flow.

nurses’ workload

--Designed a handout of discharge instruction.

--Worksheet --Handout of discharge instruction

All nurses could conduct the formalized discharge planning as

--Two posters

expected.

--Two senior nurses

The number of

--Made two posters. Nurses lacked

--Emphasized the

Motivation to make a

importance of patient

phone call to

follow-up.

reinforce self-care instructions.

--Two senior nurses were assigned to conduct the telephone follow-up.

--Outline of telephone follow-up --Head nurses’

patients who received telephone follow-up partly increased.

monitoring

--Made the outline of telephone follow-up. --The head nurse monitored the nurses’ performance.

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Phase 3: Follow-up audit Figure 2 presents the follow-up audit results, compared against the baseline results. Among the 21 patients, the compliance rates for criterion 1 (use of discharge checklist), criterion 2 (a structured patient education), criterion 3 (six components of patient education), and criterion 4 (outpatient clinic visit scheduled) reached 100% in the follow-up audit. The compliance rate for criterion 5 (telephone follow-up) attained 76%. Not surprisingly, criteria 2 and 4 achieved the least improvement in compliance rates, as baseline measures already showed a high degree of compliance. Compliance rates for criteria 1, 3 and 5, which were the lowest at baseline, showed the greatest improvement at follow-up. Overall, there was improvement in compliance for all best practice recommendations.

Figure 2: Compliance with best practice audit criteria in follow-up audit compared to baseline audit (%)

Discussion This project aimed to promote evidence-based discharge planning for HF patients admitted in the CCU of Zhongshan Hospital. Following an audit and feedback cycle using the JBI-PACES and GRIP tools, the

project

achieved

improvements

in

compliance

with

best

practice

recommendations.

Post-implementation audit showed 100% compliance with all evidence-based recommendations, except for one (i.e. telephone follow-up) which achieved 76%. At baseline, the audit showed that most patients had already been receiving discharge education. However, the coverage and depth of the education were not adequate. Only 7% of the sample had received education which covered all six aspects identified in best practice literature, i.e. diet, discharge medications, activity level, follow-up appointments, daily weight monitoring and strategies to address worsening symptoms. The reason might be that some nurses lacked knowledge of what should comprise patient education. To address this issue, all nurses in the CCU were required to attend a training program. After attending the seminar and practice demonstration, all nurses demonstrated improvements in knowledge, as shown in their examination results. Nurses’ skills in educating patients also improved as a result of the supervision provided by a senior nurse. The majority of nurses expressed satisfaction with the training and agreed that it helped a lot in informing their discharge

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planning practices. However, observations from the head nurse found that the quality of education provided to patients varied between junior and senior nurses. Patient education provided by junior nurses was not as thorough or comprehensive as that of the senior nurses. This may be due to poor communication skills or lack of confidence on the part of junior nurses. Strategies to improve nurses’ competence and confidence to deliver evidence-based discharge education should be implemented accordingly. Prior to this project, there was no discharge checklist for patients with HF. Nurses were not required to complete a discharge assessment as it was believed to be the doctor’s duty to perform such an assessment. In order to overcome this barrier, the project team translated and modified the English version of HF discharge checklist.17 All nurses were then educated about the importance of performing an assessment and how the checklist should be used to complete the assessment of a HF patient for discharge from the CCU. Following implementation of these strategies, all nurses completed an assessment using the discharge checklist. While there was improvement in practice, most nurses complained that the checklist was too complicated and time-consuming. To facilitate its uptake in the future and ensure sustainability, they suggested that the checklist be modified into a much simpler instrument which could be completed in a shorter amount of time. Initial discussions within the project team have already occurred and plans for modifying the instrument are underway. Post-discharge support is often neglected by health care workers in tertiary hospitals.22 In Zhongshan hospital, most nurses in the CCU believe their duty of care is confined within the boundaries of CCU and that any service after patient discharge is beyond their responsibility. This was reflected in the baseline audit – none of the discharged patients received a telephone or home visit. Understanding this situation, the project team emphasized the importance of patient follow-up during the educational seminar. Since it would be difficult for nurses to conduct a home visit, a telephone follow-up was preferred for this project. Two senior nurses were nominated to undertake the telephone support, with continuous monitoring from a head nurse. While these strategies were helpful in improving practice, the follow-up audit revealed that only 76% of the sample received telephone support. Following a conversation with the senior nurses, it was found that for patients who did not receive telephone follow-up, either a wrong number was in their records or calls were not answered. This highlights the need to ensure accuracy of patient information documentation. The senior nurses also expressed concern about the increase in their workload as a result of this additional task. In the future, nurses in other wards with a lighter workload, nursing students or other health care providers with appropriate training could be assigned to undertake this role. Furthermore, incentives could be provided to nurses to improve compliance. In the process of implementing the different strategies, the project team found that a formalized discharge planning process greatly increased nurses’ workload. It also became very apparent that nurses’ awareness and knowledge about evidence-based practices were very limited. Effective strategies should be in place in order to sustain the improvements observed in this project. The discharge education offered to patients could be presented on a video that plays continuously in the hospital. This would not only allow patients to watch the video at their convenience but also supplement if not replace the face-to-face education delivered by nurses. In addition, an app might also be developed to reinforce self-care instructions for discharged patients and as a reminder. Regarding nurses, evidence-based practice education programs should be conducted regularly to improve not only their awareness but also their knowledge and skills on evidence-based nursing. They should be

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given dedicated time or opportunities for continuing professional development and education. Support from hospitals or the government is integral in fostering the implementation of evidence-based practice. The five-month best practice implementation project has resulted in positive changes in discharge planning for HF patients. Informal interviews with patients demonstrated that they were satisfied with the overall process for discharge planning. They reported that they received better care from nurses, learned more about self-care, and felt more confident in managing themselves. This is critical feedback which can reinforce the continuous implementation of the strategies proposed in this project, thereby maintaining the improvements in practice that could lead to better patient outcomes. There are some limitations to this project which should be considered when interpreting the results. First, the follow-up audit was conducted in summer when HF admissions are low. Therefore, only 21 HF patients were included in the follow-up audit. Second, this project did not measure patient outcomes but rather the processes of care. Whether or not the project leads to improved health outcomes remains unknown. More research should be conducted in the future to evaluate the effect of the evidence-based discharge planning on patients’ QoL and readmission rates.

Conclusion The evidence implementation project which utilized a clinical audit process led to improvements in practice behavior related to discharge planning of HF patients. The project demonstrated that a variety of strategies, such as an effective training program, and an optimized worksheet and supervision from a head nurse, can facilitate implementation of evidence into clinical practice. The project was successful in developing a formalized practice for discharge planning and in increasing nurses’ knowledge and skills in this area. Future plans and ideas for continuous improvements in CCU practice are in place and have been discussed. Further audits will need to be carried out in order to monitor practice and effect change as required.

Conflict of Interest The authors declare that there were no conflicts of interest.

Acknowledgements I would like to thank School of Nursing, Fudan University, for providing the funding and opportunity to undertake the JBI Evidence-Based Clinical Fellowship Program. I would also like to thank the support provided from Zhongshan Hospital, especially the CCU. I would also like to thank the Joanna Briggs Institute, its staff and advisers for their assistance in the project, especially Dr Yifan Xue and Dr Lucylynn Lizarondo, who assisted me in topic selection, information providing, protocol writing and report revision.

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14. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc. 1990; 38(39): 1290-1295. 15. Chen LY. The assessment and discharge planning for hospitalized heart failure patients prior to discharge. South China Journal of Cardiovascular Disease. 2010; supplement: 35-36. 16. Grady KL, Dracup K, Kennedy G, Moser DK, Piano M, Stevenson LW. Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation. 2000; 102(19): 2443-2456. 17. The American Heart Association and the Heart Failure Society of America. Heart Failure Discharge Checklist. 2013. [Internet]. [Cited 2015 Aug 19]. Available from: https://www.heart.org/idc/groups/heart-public/@private/@wcm/@hcm/@gwtg/documents/dow nloadable/ucm_434627.pdf. 18. NHS. Principles for best practice in clinical audit. 2002. [Internet]. [Cited 2015 Aug 19]. Available from: http://www.uhbristol.nhs.uk/files/nhs-ubht/best_practice_clinical_audit.pdf . 19. Dulko D, Hertz E, Julien J, Beck S, Mooney K. Implementation of cancer pain guidelines by acute care nurse practitioners using an audit and feedback strategy. J Am Acad Nurse Pract. 2010; 22(1): 45-55. 20. Choi M. Pain management among patients with cancer in an acute care setting: a best practice implementation project. JBI Clinical Fellows Monographs. 2010; 84-89. 21. Brislin RW. Back-translation for cross-cultural research. J Cross-Cult Psychol. 1970;1(3): 185-216. 22. Liu G. The effect of telephone follow-up on knowledge level, quality of life, readmission rate and emergency-visit rate of heart failure patients. Master Thesis. Peking Union Medical College, 2009.

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Appendices The following appendices are available in Chinese. Please contact the corresponding author. Appendix I: Examination paper for nurses Appendix II: Questionnaire for patients Appendix III: Handout for discharge education Appendix IV: Chinese version of the HF discharge checklist Appendix V: Nursing worksheet Appendix VI: Education posters Appendix VII: Outline for telephone follow-up

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Role of sedation for agitated patients undergoing noninvasive ventilation: clinical practice in a tertiary referral hospital.

Exergaming in older adults: a scoping review and implementation potential for patients with heart failure.

Chronic Heart Failure Care Planning: Considerations in Older Patients.

Ocular knowledge and practice among type 2 diabetic patients in a tertiary care hospital in Bangladesh.

Palliative sedation for terminally ill cancer patients in a tertiary cancer center in Shanghai, China.

Information without Implementation: A Practical Example for Developing a Best Practice Education Control Group.

Recent developments and best practice in brachytherapy treatment planning.

Planning a research project.

Association between length of hospital stay and implementation of discharge planning in acute psychiatric inpatients in Japan.

Diagnosing Sleep Apnea in Patients Hospitalized With Heart Failure: A Role for Advanced Practice Nurses.

Short-term outcomes after hospital discharge in patients admitted with heart failure in Abeokuta, Nigeria: data from the Abeokuta Heart Failure Registry.