Running head: EVIDENCE-BASED PRACTICE CLINCAL GUIDELINE

Evidence-Based Practice Clinical Guideline Jenny Kim Professor Barry Methodist University 8 November 2013

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE Introduction Heart failure proves to be a problem in the United States healthcare system. Every year approximately 550,000 people are diagnosed with heart failure in the United States (DelgadoPassler, & McCaffrey, 2006). It is estimated that the United States spend approximately $29 billions each year for hospitalizations in which 20-50% of those patients will be rehospitalized (Delgado-Passler, & McCaffrey, 2006). Patients with heart failure are a huge contributor to increasing cost, and insurance payouts. The number of readmissions within thirty days is astounding because this is considered a controllable factor. The phenomenon of heart failure is increasing and health care professionals need to find a way to decrease readmissions, costs, and resources. The purpose of this paper is to implement nurse led interventions in order to decrease readmission of heart failure patients. Definition of Terms Heart failure: This is when your heart is not pumping proficiently. The heart cannot efficiently supply the body with nutrient rich blood. The heart tries to compensate enlarging chambers, pumping faster, narrowing the blood vessels, and decrease blood flow to less important organs.

Heart failure is described as chronic and progressive and there is no known cure (Retrieved from http://www.heart.org). Health literacy: The capacity to obtain, process, and understand basic health information and services to make appropriate health decisions (Retrieved from http://www.cdc.gov). Assessment: The act of making a judgment of something: the act of assessing something (Retrieved from http://merriam-webster.com).

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE Patient-Centered Communication: Communication that is aimed towards the patient. This is the key to quality care. Good communication is necessary to avoid errors, improve quality, save money, and achieve better health outcomes (Retrieved from http://www.ama-assn.org).

Discharge planning: A process used to decide what a patient needs for a smooth move from one level of care to another (Retrieved from http://www.caregiver.org). Standard of care: The watchfulness, attention, caution and prudence that a reasonable person in the circumstances would exercise (Retrieved from https://www.legaldictionary.thefreedictionary.com). Adherence: sticking to or being faithful (Retrieved from https://www.vocabulary.com) Symptoms: general subjective, which means what the patient feels (Retrieved from https://www.medicalnewstoday.com). PICO This author found that this increase in readmission with heart failure is preventable and could be nurse driven. The PICO question that this author developed is based on heart failure patients. The patient and problem is to prevent re hospitalization for heart failure patients. The population is heart failure patients that are hospitalized. The interventions that this author proposes is based on assessments, teaching, and post discharge follow-ups. The goal of the interventions would be to enhance teaching and learning during hospitalization. The author would compare an intervention group versus usual treatment group to see the effectiveness of the intervention. The proposed outcome would be that nurses will be able to decrease the amount of heart failure patients by providing correct assessments, patient centered information, and post discharge follow-ups. Literature Review

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This author will review five journals that relate to heart failure patients and readmissions (see Appendix for complete proofs). In this literature review the author will identify the purpose of the article, the design, sample size, data collection, results, and limitation of all five articles. After reviewing the article, using the John Hopkins Nursing Evidence Based Practice tools to level the evidence. There are two tools available that can be utilized to level the evidence depending on the type of evidence; for example, non-research based evidence appraisal versus research based evidence appraisal. Some of the articles had conflicting reviews, such as the use of telephonic nursing to decrease hospital readmissions. Riegel et al (2002) found that telephonic nurse case management for patients with heart failure after discharge proved as a beneficial resource. On the other hand, Sochalski et al (2009) examined telephonic nursing and found that it is not the most effective way to prevent readmission to the hospitals. When the author was investigating this conflict, she looked at the different telephonic programs available in each study. In the study conducted in 2002 the nurse case managers were proactive in calling patients and spent an average of sixteen hours with patients over a six-month span, which reduced readmission to hospital about 47.8% by six months compared to the usual treatment group (Riegel et al, 2002). Riegel et al (2002) also found that individuals in the telephonic intervention group occurred less cost in the hospital when readmitted. The differences between the groups were about a thousand-dollar difference. The author looked at the other evidence presented in 2009 and found that the intervention group for telephonic nurse-case management called the patients for a follow up after discharge and then did not call again (Sochalski et al, 2009). The patient had the capability to call the nurse case manger at any time, but most patients did not utilize this service. Upon further analysis, this

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE author suggests that telephonic nurse case management is helpful if it is a longer term program with proactive nurses and patients. In another article from Boulding, Glickman, Manary, Schulman, & Staelin (2011)

investigated the relationship between patient satisfaction during hospitalization and readmissions within thirty days. The emphasis in this article included patient centered information during discharge and how the patient felt after discharge. The data showed that patients with higher satisfaction rates and better discharge planning were less likely to be readmitted within thirty days. Nielsen et al (2008) guideline on transitioning patients from hospital to home stresses the important of assessment, teaching, communication, and post care follow up. The pressure on healthcare professionals to really teach patients and cater to his or her learning style is proving to decrease hospital readmissions. The author did not find an article by Robertson et al (2012) helpful in her search for interventions to decrease hospital readmissions. This article provided statistics for heart failure patients in Australia. Using Australias data to predict readmission for the United States is a farfetched idea. The article does not have any interventions that they tested that would be helpful in this authors search to prevent readmissions in the United States. Action Plan In the guideline written by Nielsen et all (2008) there is a big emphasis on assessing, teaching, and post discharge follow up. All evidence points to these three points essential actions that can significantly reduce readmissions before thirty days. All of these interventions can be carried out by registered nurses and can significant reduce cost and resources from heart failure readmission patients. The registered nurse is in contact with the patient the most and has the highest influence rate on patient whether it is good or bad. Therefore, this action plan is directed

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE towards registered nurses to enhance these three areas in order to have a nurse led outcome that has a significant outcome on the healthcare system.

The first part of the plan is to enhance assessment performed by nurses performed at admission in order to get a better idea of the patient needs during periods of education. The nurse needs to assess the patients health literacy, interest in learning, wh y the patient got admitted, other individuals involved in care, and home environment. Once the registered nurse has identified all these areas then he or she could better formulate an individualized plan that the patient is more likely to adhere to. A way a hospital can implement better assessments is to create a standardized assessment form that encompasses all aspects of the enhanced admission assessment. The hospital can get leaders from different disciplines such as physicians, nurses, social work, psychology, and others to collaborate together to generate an ultimate admission assessment. The nurses can implement this enhanced assessment and then have patients fill out discharge survey of what they thought of care, comprehensiveness of information presented, how well they understood, and how the nurse responded to the questions. These surveys can serve as an assessment to how effective the enhanced assessments are over time. The second nurse led intervention is to enhance teaching and learning. The intervention mentioned above will set up foundation of patients needs, so that nurses can implement the most effective teaching style to that specific patient. The guideline stresses the important of patient adherence to discharge instructions to prevent readmissions. The registered nurse should have different learning aids to enhance learning such as: written material, videos, audio recordings, face to face discussions, interpretive services, emphasized teaching, and so forth. If the registered

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE nurse identifies other individuals that are responsible for care of the patient, the nurse will include all personnel in the teaching.

The final intervention that can be led by a nurse include post discharge follow-up. In this authors research, it was found that frequent communication and multidisciplinary collaboration contributed to overall decrease in readmissions of heart failure patients. Telephonic nurse casemanagement seemed to improve overall health of heart failure patients, but the key to success is nurse-patient proactive interaction (Riegel et al, 2002). This author would like to propose a program for heart failure patients that is ran by the hospital in over to reduce readmissions. The program would include a series of things such as 24-hour telephonic nurse-case manager, face-to-face appointments, and multidisciplinary collaboration for best possible plan after discharge. The name of this program would be keep your heart health organization ran by the hospital. This program could be targeted towards patients with heart problems, not just heart failure. The hospital would hire additional telephonic nurse-case manager nurses to work shifts in order to provide services. This would be a nurse ran organization with the collaboration of other healthcare professionals. There is a concern that this organization would increase hospital cost, but when compared to the cost of readmission rates, the benefits outweigh the risks. Evaluation This author is suggesting that these nurse led interventions will result in significant decrease in hospital readmission for heart failure patients. Nurses are the largest work force in the health care system and have the most influence on patient because of the number of hours of contact. It just makes sense to have nurses as our first line of dense to educate patients about their conditions and how to prevent readmission. The ultimate goal from decrease readmission of heart failure patients is to decrease cost, resources, and improve quality of life for these patients.

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In order to measure the effectiveness of the interventions, there will be patient survey that is provided at the end of discharge asking questions pertaining to care, teaching, and assessment. The patients will also be asked to sign a consent form in order to monitor their readmission to the hospital. These methods will measure what the patient perceived during discharge instructions and if they are readmitted or not. These methods will measure the effectiveness of these interventions. If it is found that the hospital has a lower admission rate then it will be a hospital wide protocol to implement these nurse led interventions to prevent readmissions of all chronic illnesses.

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE References Boulding, W., Glickman. S., Manary, M., Schulman, K., & Staelin, R. (2011). Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The American Journal of Managed Care, 17(1), 41-48. Delgado-Passler, P., & McCaffrey, R. (2006). The influences of postdischarge management by nurse practitioners on hospital readmissions for heart failure. Journal of the American Academy of Nurse Practitioners,18(1), 154-160. Nielsen, G., Bartely, A., Coleman, E., Resar, R., Rutherford, P., Souw, D., & Taylor, J. (2008). Transforming care at the bedside how-to guide: Creating an ideal transition home for patients with heart failure. Cambridge, MA: Institute for Healthcare Improvement. Robertson. J., McElduff, P., Pearson, S., Henry, D., Inder, K., & Attia, J. (2012). The health services burden of heart failure: An analysis using linked population health data-sets. BioMedical Central Health Services Research, 103(12). Riegel, B., Carlson, B., Kopp, Z., LePetri, B., Glaser, D., & Unger, A. (2002). Effects of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Archives of Internal Medicine, 162(6), 705-712. Sochalski, J., Jaarsma, T., Krumholz, H., Laramee, A., McMurray, J., Naylor, M., Rich, M., Riegel, B., & Stewart, S. (2009). What works in chronic case management: The case of heart failure. Health Affairs, 28(1), 179-188.

EVIDENCE-BASED PRACTICE CLINICAL GUIDELINE Appendix Table 1

Author & Year Title Question/Purpose

10

Design

Sample

Data Collection

Findings

Limitations

Level of Evidence

Riegel, B., Carlson, B., Kopp, Z., LePetri, B., & Unger, A. (2002). Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure The article investigated the use of telephonic standardized nurse case management as a resource for patients with chronic heart failure. The authors want to see if ultimately the telephonic program for heart patients will decrease resource use. This article is a randomized control clinical trial that explores effectiveness of standardized nurse case management telephonic services for chronic heart failure. This study takes into account the resources used such as hospitalization rates, multiple hospitalizations, emergency department visits, and etc that are measured at three and six months. The randomized controlled study included 281 physicians that were randomized. The study included 358 chronic heart failure patients who spoke English or Spanish. The study excluded patients with cognitive impairment, psychiatric illness, severe renal failure requiring dialysis, terminal disease, discharge to a long-term care facility, or previous enrollment in a heart failure disease management program. The patients that were involved signed a consent form that allowed the authors to gather automated financial records at three and six months. If the patient used an out of system for care then the patient would report it at three and six months. The research showed significant difference between the intervention group versus the usual treatment group. The rates of readmissions were 47.7% lower in the intervention group oppose to the usual treatment group. The researched showed the intervention group also cost less when hospitalized compared to the usual group. Patient satisfaction was significantly higher in the intervention group. Overall, the authors of this study conclude that telephonic nurse case management is helpful in lowering readmission of chronic heart failure patients. The authors did not randomize patients, but did randomize doctors. This could indicate sample selection bias. This study did not include a wide variety of heart failure patients because of their exclusions from the sample. Most of the heart failure patients were older patients with a mean of 72 years old. Level 2, Quality B

Table 2
Author & Year Title Question/Purpose Sochalski, J., Jaarsma, T., Krumholz, H., Laramee, A., McMurray, J., Naylor, M., Rich, M., Riegel, B., & Stewart, S. (2009). What works in chronic care management: The case of heart failure The article reexamined data from ten clinical trial of care management

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11

Design

Sample

Data Collection

Findings

Limitations

Level of Evidence

program for heart failure. The aim of this article is to find methods or interventions that will reduce readmissions. This is a nonexperimental correlational that investigates important management in chronic heart failure patients from ten clinical studies in order to decrease hospital readmissions. This is a quantitative study that encompasses ten clinical studies with 2,028 cases, 961 program patients, and 1,067 routine care patients in four different countries. The authors analyzed the ten clinical studies regarding chronic heart failure. The database of this study included pooled individual-level data. The study need patients with key level variables such as sociodemographics and clinical characteristics. The researchers then complied the data and developed their own common level of measurement to ensure the data was leveled the same way in their research. The authors found that programs that incorporated multidisciplinary teams and in-person communication led to 25% fewer hospital readmissions and 30% fewer readmission days. This study did not see significant reduction in readmission from interventions including telephone follow-ups or patient in routine care. The studies did not have enough data to assess the cost implications associated with quality improvement programs. Study selection bias is another limitation. The number of studies involved in this article is extremely low and can include limitations on interventions. This studies findings conflict with other studies because of population based effectiveness programs versus controlled efficacy studies. Level 5, Quality B

Table 3
Author & Year Title Question/Purpose Nielsen, G., Bartely, A., Coleman, E., Resar, R., Rutherford, P., Souw, D., & Taylor, J. (2008). Transforming care at the bedside how-to guide: Creating an ideal transition home for patients with heart failure. The purpose of this guideline is to provide interventions for healthcare professions to implement on chronic heart failure patients in order to reduce readmissions. This guideline is divided into sections that will aid the health care professionals in successful implementation of suggested interventions. The first section has four key components for an ideal transition home for heart failure patients. The second section is a step by step sequence of activities in order to increase compliance. The final section include tools and resources for healthcare professionals. The guideline used 66 qualitative and quantitative studies. The Robert Wood Johnson Foundation developed their heart failure patient guideline through 66 evidence-based research. The guideline proposes a positive relationship between facilities that use this guideline and decline in heart failure readmissions. The guideline was released in 2008, but the guideline does not have an

Design

Sample Data Collection Findings

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Limitations

Level of Evidence

evaluation section that talks about facilities that have implemented the suggested interventions and their findings. The evaluation of the evidence-based research used to develop this guideline was not discussed. The authors did not explain how they collaborated 66 different studies or a common measurement tool. This could indicate selection bias. Level 3, Quality A

Table 4
Author & Year Title Question/Purpose Boulding, W., Glickman, S., Manary, M., Schulman, K., & Staelin, R. (2011). Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The purpose of this article is to find out if patient satisfaction had an impact on patients with chronic illness and readmission within 30 days. This study was a non-experimental descriptive design. The author observed patients with chronic illnesses and measured their satisfaction, and readmission rates over time. The chronic illness include patients with acute myocardial infarction, heart failure, and pneumonia. This quantitative study included 4469 hospitals, and 430, 982 including patients with myocardial infarction, heart failure, and pneumonia. The study used two major data sources that include the hospital compare data base by the US Department of Health and Human Services and HCAHPS satisfaction survey. From the data in the article, the authors suggest there is a correlation between patient satisfaction and reduction of 30 day readmissions. The most important role during the healthcare professional played was a teacher during discharge. If the health care professional provided patient centered information during discharge, then it played a significant role in reduction of readmissions. Since the authors did not conduct the study they could not have manipulated factors such as patients filling out satisfaction survey after discharge. There is a risk that patients filled out the survey after a second readmission to the hospital. The study does not take into account patient compliance and access to primary care, so analysis is limited. Level 4, Quality C

Design

Sample

Data Collection

Findings

Limitations

Level of Evidence

Table 5
Author & Year Title Robertson, J., McElduff, P., Pearson, S., Henry, D., Inder, K., & Attia, J. (2012). The health services burden of heart failure: an analysis using linked

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13

Question/Purpose

Design

Sample

Data Collection

Findings

Limitations

Level of Evidence

population health data-sets. The aim of this study is to assess the typical profile, trajectory, and resource use of a cohort of Australian patients with heart failure using linked population-based, patient-level data. The researchers used admitted patient data along with death registrations during the year 2000 through 2007. They analyzed geographic information pertaining to the patients, risk factors for hospital readmissions, mean length of stay, median survival and beddays occupied by patients with heart failure. Hospital admission for heart failure patients in Australia from 20002007. Total number of people involved in this study was 29,161 during a seven year span. The authors used a data-set through Centre for Health Records Linkage. The data drawn are from NSW admitted patient data collection, and registry of birth, deaths, and marriages. The rates of readmission for males and females remained steady over the course of the study. Most of the readmissions fell between 75 85 years old. This shows the importance of discharge instructions on elder heart failure patients. The whole study relies on the accuracy of data linkage studies, study definitions, and the validity of the coding in the hospital records. The study did not define why the patients were getting readmitted. Level 5, Quality C