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Critical Care Nurse. 2003;23: 39-48
Copyright © 2003 by the American Association of Critical-Care Nurses.
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Clinical Article

Teaching Documentation Tool: Building a Successful Discharge

Shauna Andrus, RN, BSN
 Janet Dubois, RN, BSN
 Chandra Jansen, RN, BSN
 Victoria Kuttner, RN, BSN, MBA
 Nancy Lansberry, RN, BSN
 Lisa Lukowski, RN, BSN

All authors are members of the ventricular assist device resource team at the University of Washington Medical Center, Seattle, Wash. Shauna Andrus is assistant nurse manager in the cardiothoracic intensive care unit, mechanical assist device coordinator, and chair of the team. Janet Dubois is assistant nurse manager in the cardiothoracic telemetry unit. Chandra Jansen was a staff nurse in the cardiothoracic telemetry unit. Victoria Kuttner and Nancy Lansberry are staff nurses in the cardiothoracic intensive care unit. Lisa Lukowski is a staff nurse in the cardiothoracic telemetry unit.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

A teaching documentation tool was created for the education of patients with the HeartMate Vented Electric Left Ventricular Assist System (VE LVAS, Thoratec Corp, Pleasanton, Calif ). The HeartMate VE LVAS is a device that provides cardiovascular support to patients waiting for a heart transplant. This device allows those patients to wait at home rather than in the hospital. In the past, patients could wait in the hospital for up to a year, unable to be discharged without a transplant. Convalescing at home with the HeartMate VE LVAS allows patients to recover from some of the debilitating effects of their cardiac disease and subsequent hospitalization. They can return to work or school and are able to lead far more normal lives.

In this article, we describe the development of a tool used to educate patients and evaluate educational and clinical outcomes. The staff at the University of Washington Medical Center, Seattle, Wash, initially felt overwhelmed by the vast body of knowledge required to care for patients with a HeartMate VE LVAS and the responsibility of teaching this information to patients and patients’ families. By remaining focused on patients’ needs required for discharge, staff nurses developed a program to prepare these patients for discharge home with the HeartMate VE LVAS.


   Background
Top
 Background
Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
 Bibliography
 
Heart failure is defined as the inability of the heart to effectively pump oxygenated blood to meet the metabolic demands of the body. This devastating condition affects 4.7 million people a year in the United States alone.1 When conventional medical therapies are unsuccessful, cardiac transplantation is an option for treatment and to prolong life. Unfortunately, only 2300 patients each year receive heart transplants, because the number of patients awaiting transplants far exceeds the number of organs available.2

Implantation of the HeartMate VE LVAS provides a bridge to transplantation by maintaining blood flow sufficient to meet the metabolic demands of the body. Thus the patient can wait at home, maintaining an acceptable quality of life while waiting for a transplant. The increased flow of oxygenated blood to organs and tissues provided by the HeartMate VE LVAS enables patients to attain better physical conditioning.

In addition, patients who used the HeartMate VE LVAS improved in the psychological, emotional, and social aspects of their lives when discharged home. They fared significantly better than transplantation candidates without an LVAS at home and better than inpatients with an LVAS. Thirty percent of outpatients with an LVAS were able to return to work or school, 33% to sexual activity, and 44% to driving. All outpatients who had an LVAS were able to perform activities of daily living.3

With the HeartMate VE LVAS (Figure 1Go), patients are free to move around on battery power without pushing the console that other left ventricular assist systems require. Using battery power, patients can take walks, bicycle, and use exercise equipment for physical conditioning. With proper training, patients can leave the hospital and wait for their transplant at home.



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  		Figure 1 The HeartMate Vented Electric Left Ventricular Assist System (VE LVAS) consists of an implanted pump and a percutaneous lead, which connects to a system controller and then to a power source (power base unit [PBU] or batteries). The pump is made of titanium and is approximately 5 cm (2 in) thick and 10 cm (4 in) in diameter. It weighs 1.2 kg (2.6 lb) and consists of 2 chambers: the blood chamber and the air/motor chamber separated by a flexible diaphragm. Inside the pump, the surfaces are specially textured to help form a lining that mimics the lining of blood vessels. This feature helps prevent formation of blood clots within the pump; thus, patients do not require anticoagulation as with other ventricular assist devices. The HeartMate VE LVAS contains porcine valves, guiding blood to flow in 1 direction only: through the pump and into the aorta. The HeartMate VE LVAS depends on preload to fill, just as a native ventricle does. The pump rate responds to the amount of blood returning to the heart, increasing to meet the needs of an exercising body and decreasing when the patient is at rest.

 

   Development
Top
 Background
 Development
Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
 Bibliography
 
Before discharge, patients must learn to care for themselves and manage their equipment. They learn about emergency procedures and equipment, care of the exit site for the percutaneous lead, and how to change power sources safely. They must demonstrate the understanding of multiple alarms, including the required corrective actions. In addition, patients learn what signs and symptoms to monitor and report to the mechanical device coordinator. A teaching documentation tool provides a comprehensive approach to organizing and documenting the required education.

When this program was started in 1998, published nursing literature about the HeartMate VE LVAS was limited. As a result, it was necessary to develop a knowledge base and staff education program based on a literature review, the manufacturer’s handbook, contact with other hospitals, and use of the actual equipment. Staff nurses from the cardiothoracic intensive care unit and the acute care unit joined to create a ventricular assist device resource team. This group developed a comprehensive program to provide thorough teaching of patients and to ensure quality care and education from implantation to transplantation.

The team members ascertained outcomes of patients and learning needs to be addressed. This information facilitated the development of a teaching documentation tool to provide consistency in education and adequate documentation of the teaching of patients and the patients’ family members.


   Teaching Patients
Top
 Background
 Development
 Teaching Patients
The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
 Bibliography
 
Teaching patients and documenting what has been taught are always important but especially when preparing for the discharge of patients with complicated, life-sustaining equipment such as the HeartMate VE LVAS. Because most patients who have these systems are adults, the principles of adult learning were an important consideration. Adult learning is dynamic. It is "typically self-directed and self-initiated . . . oriented toward immediate application and toward solving real-life problems of the learner."4 In addition, teaching of patients incorporated the 7 steps of the process model described by Knowles5 (Table 1Go).


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  		Table 1 Knowles’s process model for adult learning5

 
The patients’ educational program encompassed an overview of general postoperative surgical care and basic concepts related to the HeartMate VE LVAS. Ideally, these topics would be covered preoperatively with each patient and his or her family, but many situations did not allow preoperative teaching. For example, 2 patients went directly from the cardiac catheterization laboratory to the operating room for implantation on an emergent basis. When preoperative teaching was not possible, education began with the patients’ family members immediately after surgery and included basic information such as how to operate the HeartMate VE LVAS, possible outcomes for patients, and healing concerns. Specific content depended on the family’s readiness to learn and how quickly they were able to grasp the material presented. The nurse caring for each patient was key in assessing the readiness of the patient’s family to learn. Even before the patient was fully awake and extubated, some families were ready to begin learning specifics such as the importance of preventing infection and how to switch power sources safely.

In order to be discharged, patients must demonstrate a thorough understanding of and be competent with their care and equipment. For example, an improper change of power source could cause the pump to stop, endangering the patient’s life. Infections after LVAS implantation are common; in most studies, the prevalence is 30% to 50%.6 Proper care of the exit site and recognition of signs and symptoms of infection are of the utmost importance. The air vent is necessary to allow free flow of air between the pump and the atmosphere. Fluid entering the air vent can damage the implanted pump itself, in the worst-case scenario causing the motor to seize and stop. All of this information must be verbalized, and the skills related to proper care of the exit site and recognition of signs and symptoms of infection must be demonstrated by the patient before discharge.


   The Teaching Documentation Tool
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
 Bibliography
 
Organization of the numerous educational topics was key to the success of the program. Thorough documentation of the outcomes of teaching patients is vital for enhancing teaching efforts and continuity of care and for enhancing communication and cooperation among team members.7 "To ensure effective methods of documentation in all settings, current systems must be assessed and revised when appropriate."8 The tool was essential for documenting the educational content, monitoring the patient’s progress in learning the information, ensuring consistent teaching, and communicating to other nurses about material that had been covered. The teaching documentation tool that was developed provided guidance through the objectives that were established for teaching patients and their families.

Topics for teaching patients, such as the system controller, were broken into small, manageable "microsubjects" that could be covered in a few minutes (Table 2Go). An example of a microsubject would be "demonstrates correct changing of system controller battery cell." The microsubjects enabled nurses to document exactly what was taught, to whom it had been taught, and what part of the topic needed further reinforcement.


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  		Table 2 Inclusions in teaching documentation tool

 

   Teaching Objectives
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
 Bibliography
 
The teaching documentation tool is an 8-page–long form that lists all the teaching objectives with checklists to indicate methods, outcomes, and follow-up (see Figure 2Go, a page of the form). The form starts by listing teaching objectives for the patient or the patient’s family related to postoperative care during the hospital stay (all information from the teaching tool is reprinted here with permission of the University of Washington Medical Center ©1999):



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  		Figure 2 A page of the teaching documentation tool, showing setup of form, abbreviations to use, and signatures required.

 
Review information in the patient handbook

{square} Patient has handbook States importance of pain control for activities

States understanding and demonstrates activity limitations while HeartMate VE LVAD (HeartMate LVAS and HeartMate LVAD are used interchangeably in the health-care community) in place

States understanding of emotional responses to surgery and device implantation for patient and caregiver

Demonstrates proper use of shower kit

States understanding of importance of diet in wound healing and possible need for small frequent meals

The teaching documentation tool lists the teaching objectives for the patient or the patient’s family related to home care:

States understanding of activity limitations while at home

Demonstrates accurately taking temperature

Demonstrates proper wound care of exit site

States details of follow-up care and contact person

States importance of maintaining 2-hour drive proximity to hospital after discharge

States to the nurse the equipment that must be carried on person at all times

States when to call transplant coordinator

Correctly identifies each part of the VE LVAD system:

States purpose of each part of VELVAD system:

States how often the filter should be changed and why it should be changed

Demonstrates proper change of external air vent filter

States importance of no fluids to be in contact with vent port AT ALL TIMES

The teaching documentation tool lists the teaching objectives for the patient or the patient’s family related to the system controller:

States purpose of the system controller

Correctly identifies each symbol on system controller face:

Demonstrates normal use of system controller, including:

Demonstrates controller self-test and states why it is important to check system every day

Demonstrates changing modes and identifying which mode currently in

States when to change controller battery cell

Demonstrates correct changing of controller battery cell

States reasons to change system controller

Demonstrates appropriate technique and safety factors when changing system controller

Yellow Wrench Advisories and Red Heart Alarms

States difference between yellow wrench advisories and red heart alarms

Identifies potential cause of each yellow wrench advisory

Demonstrates key interventions for each yellow wrench advisory:

Demonstrates connecting system controller to power base unit attached to display module to see cause of alarm

Demonstrates immediate action for any yellow wrench advisory until cause is known

Identifies potential cause of each red heart alarm

Demonstrates key interventions for each red heart alarm

Demonstrates immediate action for any red heart alarm until cause is known:

The teaching documentation tool lists the teaching objectives for the patient or the patient’s family related to the power base unit (PBU) and batteries:

States understanding of PBU functions and care of batteries

A/C fail

Low battery

Identifies principles of battery care

The teaching documentation tool lists the teaching objectives for the patient or the patient’s family related to changing power sources:

Demonstrates safety and correct technique in changing from PBU to batteries

Demonstrates safety and correct technique in changing from batteries to PBU

Demonstrates safety and correct technique in changing batteries only

States reasons to connect to emergency power pack

Demonstrates safety and correct technique in attaching to emergency power pack

The teaching documentation tool lists the teaching objectives for the patient or the patient’s family related to the hand pump:

States reasons to hand pump and safety factors for connection

Demonstrates appropriate hand pump technique

States proper storage of hand pump


   Implementing the Tool
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
Evaluating the Tool
 Conclusions
 References
 Bibliography
 
Preparing to implement the teaching documentation tool includes an assessment of the patient’s readiness to learn. In addition to the individual needs of adult learners, our patients had emotional issues as well as physical recovery from the surgery that affected their readiness to learn. In some instances, the patient had little if any warning before the HeartMate VE LVAS was implanted. One patient went directly from the emergency department to the cardiac catheterization laboratory and then to surgery for implantation. Waking up with the LVAS came as a complete surprise to him. Other patients had lived with heart failure for some time and were more prepared for the possibility of implantation of a HeartMate VE LVAS. For these patients, use of the device was a way to buy more time while waiting for a transplant. All of our patients needed time to adjust to the pump, not only its sounds and weight but also its constant reminder of their dependence upon this device.

Teaching was individualized to each patient’s learning abilities and educational level. With education ranging from sixth grade to graduate school, patients profited most from different learning methods. A variety of methods were used to present the information: written material, one-on-one teaching sessions, and hands-on practice with the equipment. Some of the material to be taught, such as the alarms of the HeartMate VE LVAS, is very complex and can be confusing. Flash cards were developed to simplify the information and allow patients to easily review the material whenever they had a few minutes (Figure 3Go). Patients showed achievement by verbalizing the material or demonstrating the behavioral objective. Our ultimate goal, documentation of the patient’s ability to care for himself or herself and manage the equipment, was clearly recorded.



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  		Figure 3 Flash cards used by patients to review material they have learned about their Vented Electric Left Ventricular Assist Device (VE LVAD). Front of flash card is shown at left and back of flash card is shown at right.

 

   Evaluating the Tool
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
Conclusions
 References
 Bibliography
 
The teaching documentation tool enabled us to meet our goals of organizing skills to be taught, documenting the instruction provided, and documenting the level of understanding of patients and their families. Additionally, nurses commented that the tool reinforced the nurses’ understanding of the information to be conveyed and ensured that it was covered in a clear and consistent manner. The tool also provided a means for nurses to communicate with nurses on other shifts and units as a patient’s learning progressed. Because the teaching documentation was organized in a single place, it increased efficiency in determining what skills remained to be mastered. Updating of patients’ charts was simplified by having the information already spelled out on the tool. The learning outcomes and teaching objectives were very specific, concise, and unambiguous. The necessary behaviors and self-care skills were spelled out in concrete, measurable terms.

Staff nurses were able to use the teaching documentation tool as a guide for teaching and to take an involved approach to each patient’s care. The tool reflected the complexity and depth of teaching patients that bedside nurses provided for patients with a HeartMate VE LVAS and provided valuable feedback about each patient’s readiness for discharge.

Ensuring a safe discharge required having patients demonstrate both routine and emergent care. The teaching documentation tool can be used to record a patient’s progress in learning this care. Using this tool as evidence of a patient’s readiness for release, nurses actively participated in decision making about discharging patients from the hospital. For example, a patient was confused immediately after implantation. As his mental status improved, he started asking questions about his equipment. The patient learned quickly and demonstrated the required actions competently. At this point, the bedside nurse approached the nurse practitioner in charge of the patient’s care about plans for discharge. The nurses set a specific date for discharge based on his readiness and demonstrated ability to manage his care at home.

Patients with a HeartMate VE LVAS can care for themselves safely and competently at home. When our patients who had the device called for information or to report changes, the calls were appropriate. Patients found themselves in a variety of situations, both mundane and critical, in which they showed the ability to keep a cool head, solve problems, and extrapolate from the information taught them.

For example, Mr K. was shopping for groceries when he heard an unfamiliar alarm tone. He calmly checked his system controller for an alarm, and when he did not find one, he went home to attach his system controller to his display module. When there was still no alarm message, he called the mechanical device coordinator for advice. After talking through the situation thoroughly, they were able to determine together that the "alarm" he had heard had nothing to do with his HeartMate VE LVAS but was the beeper he was given by the transplant coordinator. Even though he was unsure of the alarm, he was able to remain calm and to troubleshoot his equipment independently before calling the mechanical device coordinator.

On the opposite end of the concern spectrum, Mr B. was able not only to change his system controller at home by himself but also to change his "Y" connector. He had a cracked Y connector on one of his clinic visits, and the mechanical device coordinator helped him disconnect himself from the system controller (thus stopping his pump) and change out the cracked connector. He then needed to reconnect the system controller to his percutaneous lead and connect the system controller to power before his pump would restart. The next time his Y connector cracked, he was able to change it himself at home. Because this procedure is one that gives even experienced resource team members pause, it was particularly significant that Mr B. felt that he had the appropriate training to attempt it at home.

These examples confirm that our teaching program was comprehensive and effective. The teaching documentation tool, as both guide and record of patients’ education, is successful.


   Conclusions
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
References
 Bibliography
 
Of the 16 patients who had a HeartMate VE LVAS implanted, 12 were successfully discharged. One could not be discharged without significant rehabilitation because of blindness resulting from a hypotensive episode in the cardiac catheterization laboratory before the device was implanted. He received a transplant and was successfully discharged. Two other patients could not be discharged because they required dialysis 3 times a week, and no local dialysis center could accommodate a patient with a HeartMate VE LVAS. One patient died before his discharge planning could be finalized.

The teaching documentation tool outlines a process for educating patients and evaluating educational and clinical outcomes to facilitate successful discharge. It is a road map for teaching and documentation of each patient’s progress. The learning outcomes and teaching objectives are specific and concise while allowing individual patients’ learning styles. The necessary behaviors and self-care skills are spelled out in concrete and measurable terms. The discharge of 12 patients able to manage their self-care and equipment at home illustrates the success of the tool.


   Acknowledgments
 
We gratefully acknowledge the contributions of past members of the ventricular assist device resource team in the development of this article: Michael Powers, RN, and Margaret Bull, RN.


   References
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
Bibliography
 

  1. National Heart, Lung and Blood Institute. NHLBI-funded study finds heart assist device extends and improves lives of patients with end stage heart failure. Press release Nov. 12, 2002. Available at: http://www.nhlbi.nih.gov/new/press/01-11-12.htm. Accessed April 25, 2002.
  2. US Department of Health and Human Services. Facts about heart and heart-lung transplants. Available at: http://www.nhlbi.nih.gov/health/public/heart/other/hrt_lung.htm. Accessed April 21, 2002.
  3. Morales DL, Catanese KA, Helman DN, et al. Six-year experience of caring for forty-four patients with a left ventricular assist device at home: safe, economical, necessary. J Thorac Cardiovasc Surg. 2000;119:251–259.[Abstract/Free Full Text]
  4. Grueninger UJ. Arterial hypertension: lessons from patient education. Patient Educ Couns. 1995;26:37–55.[Medline]
  5. Knowles MS. Modern Practice of Adult Education. Chicago, Ill: Follett Publishing; 1970:54.
  6. Piccione W Jr. Left ventricular assist device implantation: short and long-term surgical complications. J Heart Lung Transplant. 2000;19(8 suppl):S89–S94.[Medline]
  7. Cornett SJ. Designing and implementing an effective patient education documentation system. In: Giloth BE, ed. Managing Hospital-Based Patient Education. Chicago, Ill: American Hospital Publishing Inc; 1993:165–203.
  8. Barnes LP. Documentation of patient teaching. MCN Am J Matern Child Nurs. 1996;21:111.[Medline]

   Bibliography
Top
 Background
 Development
 Teaching Patients
 The Teaching Documentation Tool
 Teaching Objectives
 Implementing the Tool
 Evaluating the Tool
 Conclusions
 References
 Bibliography
 
Canody CM, Savage L. The left ventricular assist device: a tool that may offer a second lease on life. Am J Nurs. May 1999;99(suppl):15–20, 50–52.

Chillcott SR, Atkins PJ, Adamson RM. Left ventricular assist as a viable alternative for cardiac transplantation. Crit Care Nurs Q. February 1998;20:64–79.[Medline]

Moroney DA, Powers K. Outpatient use of left ventricular assist devices: nursing, technical, and educational considerations. Am J Crit Care. 1997;6:355–362.

Myers TJ, Dasse KA, Macris MP, Poirier VL, Cloy MJ, Frazier OH. Use of a left ventricular assist device in an outpatient setting. ASAIO J. 1994;40:M471–M475.[Medline]

Ramsdell R, Annis C. Patient education: a continuing repetitive process. ANNA J. 1996;23:217–221.

Speers AT. Patient education: theory and practice. J Nurs Staff Dev. 1989;5:232–236.

Snyder B. An easy way to document patient education. RN. March 1996;30:43–46.

Stephens SA, Mason S, Putting it together: a clinical documentation system that works. Nurse Manage. March 1999;30:43–47.

Sullivan GH. Keep your charting on course. RN. May 2000;63:75–79.





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