Statistics from Altmetric.com
Heart failure (HF) is a syndrome of shortness of breath and fatigue. It occurs when forward flow of blood out of the heart is impeded. This is the only cardiovascular condition that continues to increase in prevalence and incidence. It is a major healthcare problem, not only for the patient, but also for significant others and the community at large. The condition accounts for approximately 12–15 million office visits and 6.5 million hospital days annually in the United States. One third of those discharged from the hospital are readmitted within 90 days because of recurrence of symptoms. The cost of HF patient care is approximately $38.1 billion annually, draining limited resources of patients, treatment facilities, and society.1–,3
Type of evidence used
To effectively deal with the problem of high HF admission rates and with the associated high number of days of hospitalisation, costs per case, and recidivism,1,4–,7 Jersey Shore Medical Center staff used a multidisciplinary approach in developing an HF centre. Evidence was retrieved from medical, nursing, and allied health literature. Existing HF centres were observed as well.
Method used to obtain and review evidence
The project manager and a physician who strongly supported the development of an HF centre visited several model HF centres in the United States. They spoke with experts in the field and gathered many ideas. Literature was reviewed to determine a “best fit” design for the planned facility.4–5,8–,12 A decision was made to have a physician directed, advanced practice nurse run centre to best serve the needs of the physicians with whom we work, and the community we treat. A decision was also made to hire an experienced advanced practice nurse (APN) with a broad cardiology background.13 The APN would run the HF programme based on guidelines developed by the project manager and medical director.
The HF centre was developed with goals mutually beneficial to patients and the facility. The outpatient portion of the programme was designed to help patients retain optimal heart health outside of the hospital. APNs would run the centre, providing collaborative care and aggressive education to referred patients as indicated in the literature.11,13 Patients would be seen on site for physical assessments and treatment as indicated in the literature.3,14–,19 Aggressive multidisciplinary education would be offered, using the resources of the hospital to provide patients with optimal care as indicated in the literature.7,20–,23 Patients would be routinely telemonitored to assess level of HF compensation.24
Decompensation, when diagnosed early, could be easily remedied. If patients required readmission to the hospital, they would likely be less acutely ill and remain hospitalised for a shorter time, decreasing length of stay as indicated by Bennett et al25 and by Rich et al.26 The advanced practice staff would also see all hospitalised patients with HF. They were to assess patients’ needs and expedite meeting those needs. The HF staff would also educate patients and provide literature for them to take home. Questions and concerns would be addressed. Diagnostic departments were to be called to ensure timely scheduling of tests. APNs were to collaborate with physicians to optimise patient care and gain referrals to the outpatient centre. Dietary consultation would be routinely requested. Case managers and social workers were given preliminary advice about potential patient discharges, so that discharge needs could be anticipated in advance of actual discharge.8,22,27–,31
How the strategies were implemented
The APN was hired. Space was set up for the outpatient centre near a telemetry unit, within easy access of the front door. 3 rooms were provided for the HF centre: an office, an examination room, and a treatment room. Office equipment and supplies were ordered including a video system and patient literature. Hands-on teaching tools and compliance aids were ordered using funds from the Heart Failure Center Foundation. A semiprivate room is used as a treatment room. In this room, patients can rest in bed while they receive diuretics or intermittent inotropic infusion therapy.32 These patients receive care from the telemetry unit nursing staff.
Free valet parking was set up for patients. Necessary forms were designed and a registrar is on site. Many meetings were held with ancillary departments to streamline every process including medical record charting, supply distribution, consultations, information technology, reporting, and finance. Multidisciplinary meetings were held with managers from nutrition, cardiac rehabilitation, clinical pharmacy, case management, and social services departments to set up support services for outpatients. Decisions were made about how best to provide excellent customer service. Meetings were held monthly to discuss progress concerning the programme. Surveys were obtained or developed to assess patients’ functional status, quality of life, and satisfaction. Such tools33–,37 are administered upon enrollment in the programme, and regularly thereafter, to assess patient progress.
For the inpatient portion of the programme, patient handouts were developed. Information technology staff assisted with implementing computerised standing orders for HF patients on the coronary care, telemetry, and medical units. Additional orders were implemented including routinely prescribed medications for HF patients. Consultation guidelines were instituted for referrals to the HF centre, and nursing staff, clerical staff, physicians, and office managers attended inservice education programmes about expectations. HF guidelines were also distributed to the medical staff as recommended in the literature.3,15
Method of evaluation
Evaluation of the inpatient portion of the programme included variables such as length of stay, cost per case, and use of HF medications such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, hydralazine and nitrate combinations, and β-blockers. These variables were compared monthly and quarterly. Audits of clinical pathway variables were performed to assess effectiveness of hospitalisation. Areas of deficiency were the focus of improvement strategies through our multidisciplinary clinical service team. The HF centre’s staff developed the first physician report card for our healthcare system. After a blinded audit, cardiologist variables were presented to the cardiology section, so that practice issues could be assessed, compared, and improved. Post-hospitalisation telephone surveys were conducted to assess patient satisfaction.
Evaluation for the outpatient programme included assessing quality of life and functional status (Minnesota Living with Heart Failure Questionnaire and SF 12) and physical endurance (Six-Minute Walk33). These were measured upon enrollment and at regular intervals. Heart failure admission rates for our enrolled patients were compared to HF readmissions for all non-enrolled patients at 30, 60, and 90 days to show the benefit of our outpatient programme. Outpatient satisfaction surveys are mailed to patients quarterly.
Hospital length of stay decreased from 8.4 to 6.5 days within 6 months. Associated cost savings to the facility were over $360 000. The first full year of operation led to continued decreases in length of stay and an additional $255 000 saved. Recidivism decreased from 33% to 13% or less
Physician report cards yielded useful information that led to awareness of prescribing practices and overall improved length of stay, cost per case, and adherence to standard HF medications. Audits of clinical pathway variables showed several areas for improvement. Resultant changes were made in areas such as (a) timely performance of 2-dimensional echocardiograms; (b) timely documentation of findings in patients’ records; and (c) more accurate medical record charting for patients with renal diseases, without heart disease. These changes led to more accurate diagnostic related group (DRG) coding with reimbursement ramifications. Inpatient satisfaction surveys indicated good recall about the HF centre staff visits and the education provided.
Quality of life evaluations for outpatients showed a 33% improvement in functional status and physical endurance, and a 25% improvement in quality of life during the first 6 months of participation with the centre. Use of ACE inhibitors was found to be better for outpatients at the centre than for inpatients—89% v 50%, respectively. Patient satisfaction with the programme remains high. Patients and family members have written letters of praise and support. Some have even contributed to the hospital’s Heart Failure Center Foundation.
Development of the HF centre was challenging. Several changes were made in the nursing care process for patients receiving intravenous inotropic infusions and diuretic therapy. Physician report cards were amended for enhanced accuracy. The clinical pathway has evolved into a process, rather than a form to be completed. Physician satisfaction surveys are currently being developed.
This hospital based, APN administered heart failure centre is an effective way to decrease length of stay and associated financial burdens to patients, our facility, and ultimately, to society. Outpatients enrolled in this programme greatly benefit from a decrease in recidivism and from improved functional status, physical endurance, and quality of life.
In 2001, the Honor Society of Nursing, Sigma Theta Tau International and Nursing Spectrum sponsored an “Innovations in Clinical Excellence” contest to recognise exemplars of evidence-based nursing practice. The following are 2 of the winning entries.
Reprinted with permission of the Honor Society of Nursing, Sigma Theta Tau International from Crowther M, Maroulis A, Shafer-Winter, et al. Evidence-based development of a hospital-based heart failure center. Online J Knowl Synth Nurs 2002;9:5C.