Discharge Readiness Assessment in Patients With Heart Failure by Registered Nurses Working in the Cardiovascular Ward

Background The Care Transitions Scale for Patients With Heart Failure (CTS-HF) is a scale that registered nurses working in the cardiovascular ward use to assess patients' readiness for hospital discharge; CTS-HF has shown sufficient reliability and validity for use. Objective In this study, our aim was to test the relationship between assessments using CTS-HF by nurses and patients' difficulties of symptom management and self-care 1 week after discharge. Methods In this longitudinal study we paired responses from nurses and patients with heart failure between 2022 and 2023. A nurse assessed a patient's readiness for hospital discharge using CTS-HF. One week after discharge, patients with heart failure completed a questionnaire about their daily difficulties at home. The relationship between the nurse-reported CTS-HF scores and patients' difficulties at home was analyzed. Results Twenty-three dyads of nurse-patient responses were included in the analysis. Nurse-assessed CTS-HF scores were significantly correlated with patients' symptom management difficulties at home ( r = −0.471, P = .012), degree of interference with daily life due to symptoms ( r = −0.530, P = .005), daily healthy ways to manage symptoms ( r = 0.561, P = .003), and emotional support at home ( r = 0.435, P = .019). Conclusions Nurse-reported CTS-HF scores showed a relationship with patients' difficulties after discharge. Because nurses' assessment before discharge may predict patients' difficulties managing symptoms after discharge, such discharge readiness assessment by nurses using CTS-HF may be useful in transitional care from hospital to home. Further studies on patients with complex care needs are warranted.