Running head: IMPLEMENTATION OF A PRACTICE CHANGE 1

Implementation of a Practice Change:

Telephonic Interventions in Heart Failure Elderly Population
Mallory Mettler
University of South Florida
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Implementation of A Practice Change: Telephonic Interventions in Heart Failure Elderly
Population
Heart failure (HF) occurs when the heart is unable to perfuse the body. HF becomes more
prevalent as the population ages and survival increases from cardiac events (Roger et al., 2004).
HF has the highest readmission rate to a hospital within a 30-day period for patients over age 65
in 2010 (Elixhauser & Steiner, 2013). Many people live with heart failure, but 80 percent of the
patients are aged 65 years or older. According to the American Heart Association, projections
show that by 2030, the total cost of HF will increase almost 120% to 70 billion from the 2013
estimated total of $32 billion (American Heart Association, 2013). More HF patients are coming
to the hospitals to get information instead of going to their primary physician. HF patients need
to receive HF education and how to live with the disease to prevent flairs that would send them
into the hospital. By creating discharge education programs and giving HF patients a trained
personnel who they can contact, HF patients should be able to stay out of the hospital unless
necessary.
PICOT Question
The initial step in this review process was the development of the following PICOT
question: In heart failure patients over age 65, how does clinically trained personnel scheduling
follow-up appointments and using telephonic interventions for patients prior to discharge
compare to having patients responsible for their own follow-up appointments influence patient
readmission to a hospital over 30 days?
Infrastructure to Support Practice Change
Morton Plant Hospital (MPH), which is part of the Baycare Health system is committed
to providing high quality patient care to the community. This commitment is reflected in the
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mission statement located on Baycare Health System website, Improving the health of all we
serve through community-owed health care services that set the standard for high-quality,
compassionate care (www.baycare.org/about-us). MPH vision is to be recognized as Floridas
pre-eminent community-focused health care organization and the leader in medicine through our
Center of Excellence. This is brought to life through the caring and commitment of team
members and physicians(http://www.mpmhealth.com). This commitment is evident through a
hospital-wide policy committee, which allows physicians, nurse practitioners, and nurses to
communicate and voice any healthcare concerns so that optimal care can be reached for patients.
MPH provides an evidence-based practice (EBP) culture that includes removing any barriers that
could hinder the implementation of EBP as a standard of care, hospital-wide mentors, and
clinicians, whose job is to advance the EBP in the hospital (Melnyk, Fineout-Overholt,
Gallagher-Ford & Stillwell, 2011). The spirit of inquiry, desire for delivering the best care
available, and a willingness by all team members to accept change based on evidence are the
guiding principles for supporting a change in practice (Melnyk & Fineout-Overholt, 2011). MPH
encourages the questioning of current practices to improve overall patient care. To make this
plan go smoothly within the Baycare System, everyone has to work together as a team. The
nurses have to make sure they are properly discharging patients with good disease education.
Case workers should evaluate patient needs like medication education and support groups.
Doctors should make sure patients understand why they have heart failure and what the patient
can do to slow any progression. The hospital has to become one team to keep patients that dont
have to be in the hospital out and healthy.
Synthesized Literature Review
Literature Search
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CINAHL and EBSCOhost were searched using the terms patient readmission, poor
compliance, heart failure, hospital readmission, knowledge, outcomes, Medicare patients,
discharge education, telephonic interventions, and follow-up appointments. Limits were set for
English language and articles published after 2010. Three peer-review studies were selected for
evaluation and synthesis.
Synthesis
Research has suggested discharge patient education and follow-up appointments play a
very important role in reducing readmission of heart failure patients to the hospital within a 30-
day period. The study performed on HF patients receiving an outbound telephonic support after
they have been discharged from the hospital was examined to significantly reduce hospital
readmission rates (Costantino, Frey, Hall, & Painter, 2013). The closer the patient received the
telephonic intervention after discharge the more likely the patient was to contact a primary
physician for any follow-up problem. This study suggests the importance of contacting patients
by telephone within a 48hour window to make sure that the transition from hospital to home
went smoothly. By having clinically trained professionals contact patients after discharge, this
can help patients who have any questions regarding follow-up appointments, HF medications,
and HF teachings get answers. Amarasingham et al. (2013) concluded that if high-risk patients
were flagged in electronic medical records at admission and these patients would first receive
help from clinically trained professionals in hospital then continued to receive help as an
outpatient to make sure appointments and any questions about HF were answered. If HF patients
over the age 65 received proper HF education during their hospital stay and after discharge from
clinically trained professional, the rate of readmission would continue to decrease over the long
run. Basically, the results from each research article showed a decrease in patient readmission
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from the hospital. Hospitals should create a policy that causes high-risk patients to be flagged
through their medical records to receive any education they may need with their diagnosis. Then,
a telephone call should be placed to the patient post-discharge to answer any questions the
patient might have and make sure follow-up appointments were made. And finally, the patient
should be advised to go to a post-discharge teaching education class that will help solidify heart
failure components and prevent readmission. However, there is no way to get patients to comply
with these heart failure recommendations in a hospital, this action creates gaps because all
patients are different and not every patient wants to get better or learn about their given illness.
These patients still need to be addressed and go through the same intervention.
Proposed Practice Change
Patients over age 65 who are more likely at risk for readmission for HF should be flagged
to receive individual HF discharge education. Costantino, Frey, Hall, & Painter (2013) found that
a direct correlation occurred between outpatient telephonic interventions and a reduction in
hospital readmission in the Medicare within 30 days. By providing these HF patients with the
resources they need for follow-up care and management of symptoms, the hospitals will save
money over time. Whether patients are flagged in their electronic medical records or every HF
patients receives the same self-care discharge teaching, this change will keep at-risk patients out
of the hospital.
Change Strategy
All stakeholders of the healthcare team which includes physicians, nurse practitioners,
nurses, social workers, and caseworkers should be encouraged to participate in the process. Any
concerns should be voiced to provide any insight to barriers that could hinder the EBP process.
Once these barriers are identified, a plan to break through will be created so that patients will
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receive the best care possible. For example, if any stakeholder voices a barrier that telephonic
intervention and detailed HF education does not work, any evidence that has been collected will
be shown to the individual. Morton Plant Hospital utilizes The Model for Evidence-Based
Practice Change (Melnyk & Fineout-Overholt, 2011) to implement EBP into their clinical setting
The first step is that the stakeholders have to identify that telephonic interventions and HF
discharge education will promote a solution to the increasing number of hospital readmissions in
HF patients. Next, a clear set of guidelines need to be created so that all stakeholders know the
standards of care that will be used based on current evidence.
Roll Out Plan
Steps Definition Timeframe for Rollout
Step 1 Assess the need for change in
practice
Include stakeholder
(nurses, doctors,
patients, case workers,
and social workers)
Collect internal data
about how HF patients
are discharged
currently
Compare various
hospital data in the
surrounding area
Identify the problem
Link the problem,
intervention, and
create an outcome
Completed September, 2013
Step 2 Locate the best evidence
Identify types and
sources
Review research
concepts
Plan the search
Organize the search
Talk to stakeholders
and patients
Completed October, 2013
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Step 3 Analyze the current evidence
Synthesize the best
evidence
Check out how
patients have
completed HF
educations
Assess the risks,
benefits, and actually
of the plan occurring
Completed November, 2013
Step 4 Design practice change
Define proposed
changes with
outpatient HF
education classes
Identify the resources
needed with nurses and
education for the
nurses
Design an evaluation
of the pilot
Design an
implementation plan
for the pilot
December 2013
Step 5 Implement and evaluate
change in practice
Implement pilot study
with HF patients
Evaluate nursing
processes, outcomes,
and costs for the
hospital
Develop conclusions
and recommendations
Implement plan January, 2014

Evaluate March 2014
Step 6 Integrate and maintain change
in practice
Explain to stakeholders
why HF education is
important for discharge
Communicate the
recommended change
to stakeholders
Integrate the new
practice into the
standards of practice
April 2014
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Monitor process and
outcomes periodically
Celebrate and
disseminate results of
project to entire
Baycare health system
Model of evidence-based practice change (Melnyk & Fineout-Overholt, 2011, p. 255)
Project Evaluation
The specific data that would be collected to evaluate the change would be measured by
Hospital Compare, which shows different hospitals overall rate of readmission for HF and
compares their rate to the U.S. national average as well as local hospitals. Beginning in January
2014, all HF patients who would be considered at risk will receive the intervention that includes
being flagged in electronic medical record, detailed discharge education, and post-discharge
telephonic communication. Data will be collected on every HF who is at risk for hospital
readmission. Comparing prior hospital readmission rates of HF patients to the rates after the
change is implemented will give an accurate projection if the intervention is working. Rates will
be followed within a monthly 30-day time frame to evaluate the intervention. An expected
outcome is a decrease hospital readmission rate for HF patients. The positive outcomes will be
evaluated and the negative outcomes that will be discovered will be changed before
dissemination.
Dissemination of EBP
Many strategies that can be used to disseminate evidence include creating oral
presentations, posters, hospital/organization-based and professional committee meetings, journal
clubs and publishing (Melnyk & Fineout-Overholt, 2011). Any of these options would increase
stakeholder involvement, which would remind them of the change and provide rationale for
supporting the practice. The first step after creating presentations would be presenting it to the
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unit leader on Morton Plant Hospital floor. The unit leader would help disseminate the project to
other units and help with the implantation process. The project should be addressed at the EBP
meeting that Morton Plant has once a month to discuss implementation. Once the project is
implemented at Morton Plant, the nurse should present the plan to the Baycare Healthcare
system and try to get the interventions processed throughout the whole system.


















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References
Amarasingham, R., Patel, P., Toto, K., Nelson, L., Swanson, T., Moore, B.,Halm, E. (2013).
Allocating scarce resources in real-time to reduce heart failure readmissions: A
prospective controlled study. BMJ Quality & Safety, 1-10. doi:10.1136/bmjqs-2013-
001901
American Heart Association (2013). Heart disease and stroke 2013 statistical update. Retrieved
from: http://my.americanheart.org/professional/General/AHA-Heart-Disease-and-Stroke-
Statistics-2013-Update_UCM_445937_Article.jsp on November 10, 2013.
BayCare Health System (n.d.) BayCare Health System Website: Mission Statement. Retrieved
from http:www.baycare.org on November 11, 2013.
Costantino, M. E., Frey, B., Hall, B. & Painter, P. (2013). The influence of postdischarge
intervention on reducing hospital readmissions in a Medicare population. Population
Health Management, 16(5); 310-316. doi: 10.1089/pop.2012.0084
Elixhauser, A. & Steiner, C. (2013). Readmissions to U.S. Hospitals by Diagnosis, 2010. Agency
for Healthcare Research and Quality, Rockville, MD. http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb153.pdf.
Kommuri, N. V., Johnson, M. L., & Koelling, T.M. (2012). Relationship between improvements
in heart failure patient disease specific knowledge and clinical events as part of a
randomized controlled trial. Patient Education and Counseling, 86(2); 233-238.
Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Stillwell, S. (2011). Evidence-based
practice, step by step: Sustaining evidence-based practice through organization policies
and an innovative model. American Journal of Nursing,111(9);57-60.
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Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing &
Healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams &
Williams.
Morton Plant Hospital (n.d.) Morton Plant Hospital Website: Mission Statement. Retrieved from
https://mpmhealth.com on November 11, 2013.
Roger,V., Weston, S., Redfield, M., Hellermann-Homan, J., Killian, J., Yawn, B.,Jacobsen, S.
(2004). Trends in heart failure incidence and survival in a community-based population.
Journal of American Medical Association, 292(3);344-350.
Schipper, J.E., Coviello, J., & Chyun, D.A. (2012). Fluid overload: Identifying and managing
heart failure patients at risk for hospital readmission. In B. C. F. Zwicker (4 ed).
Evidence-based geriatric nursing protocols for best practice (pp. 628-657). New York,
NY: Springer