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Running head: SYNTHESIS PAPER 1 Synthesis paper Carmen Valdez University of South Florida NUR 4169C, Semester 3 Professor Melissa Shelton October 20, 2013 2 SYNTHESIS PAPER Abstract The clinical problem at Florida Hospital Tampa (FHT) is an increase of hospital readmissions within 30 days post-discharge in patients with heart failure. As a result of this issue, the hospital is not being reimbursed for the care of these patients. The objective of this paper is to analyze the effects of home nurse interventions in the prevention of hospital readmissions on this population. The search engines used during this research was PubMed and CINAHL. The keywords used for this research were “preventing hospital readmission in patients with heart failure.” Results from the research reviewed were a decrease in hospital readmissions on patients who received the nurse interventions. Therefore, the healthcare team at FHT should consider home nurse care for patients with heart failure. 3 SYNTHESIS PAPER Synthesis Paper At Florida Hospital Tampa, many healthcare providers are struggling to decrease the rate of readmissions among patients with heart failure. This clinical problem not only affects the patients who are being hospitalized within 30 days post-discharge, but it also affects the hospital’s budget. According to C. Cooper, one of the clinical nurse coordinators, nurses in the care of these patients provide verbal education, as well as printed information about the management of heart failure (personal communication, October 14, 2013). However, this approach does not seem to decrease the number of readmissions. Brotons et al., 2009; Jorstad, Clemens and Alings, 2013; Stauffer et al., 2011 have shown that nurse home visits after discharge decrease the number of readmissions on patients with heart failure. For this reason the following PICOT question has been developed, in patients with heart failure, do nurse home visits compared with usual care affect the number of readmissions within 30 days? Literature Search CINAHL and PubMed were the databases used for this paper. The search terms used were heart failure, readmission, prevention. Literature Review Brotons et al. (2009) conducted a randomized control trial with the purpose to determine if home nurse visits had an impact on the amount of readmissions to the hospital. This study included 283 patients who were admitted to the hospital and had a history of heart failure. The patients were divided randomly between the control group and the intervention group. After discharge, patients in the control group were scheduled a follow-up appointment with their primary care doctor and/or cardiologist. Patients in the intervention group were visited once a month by a registered nurse, in addition to their usual care. During each visit, nurses provided 4 SYNTHESIS PAPER general information about heart failure and education about the symptoms associated with this disease. They also checked vital signs, assessed medication history and adherence, evaluated lifestyle changes, and the patient’s functional level. In addition to the home visits, nurses communicated with their patients on the phone biweekly to check on their health status. The results of this randomized control trial showed that there were 52 readmissions in the intervention group and 62 readmissions in the control group (P<.001). Furthermore, this study has some strengths that prove to be valid. The participants in this study were randomly placed in the intervention group as well as in the control group. According to Brotons et al. (2009), the health care team involved in the care of the patients was also blinded to the study. Some patients were not able to complete the study due to reasons such as cognitive issues, previous history of participation in another study within 3 months, refusal to sign consent, and death. In another study performed by Jorstad and Aling (2013), it was found that providing nurse follow-up sessions decreased the number of readmissions among patients with acute coronary syndrome. This study included 754 patients who were hospitalized for acute coronary syndrome with a history of myocardial infarction, angina pectoris, hypertension, diabetes, heart failure, and peripheral artery disease. The purpose of this study was to evaluate if nurse intervention visits would decrease the amount of readmissions in these patients. The methods used in this study consisted of four visits at an outpatient clinic during 2, 7, 12, and 17 weeks post-discharge. During each visit, nurses reviewed risk factors, medication adherence, and lifestyle changes with each patient. The nurses also analyzed diet, tobacco use, blood pressure, cholesterol, exercise, glucose level, and waist circumference. They also provided educational information to promote and carry out smoking cessation, active lifestyle, and a healthy body 5 SYNTHESIS PAPER weight. The results of this study revealed that 86 patients were readmitted in the intervention group and 132 in the control group (P=0.23). In addition, the study was valid because the participants in the study, as well as those involved in the patient’s care were blinded to the study. Some patients were excluded in this stud y due to refusal, incomplete follow-up, death, or not enough criteria met. There were 375 people in the intervention group and 379 in the control group. The age and health status of these patients were about the same in both groups. Stauffer et al. (2011) performed a randomized control trial to test if nurse home visits affect the number of readmissions in patients with heart failure. The participants in this study were 65 years old or older with a diagnosis of heart failure. The study consisted of 8 home visits for a period of 3 months. In addition to home visits, the nurse was reachable on the phone throughout the week. During these visits, the nurse had the chance to discuss the symptoms of heart failure, as well as provide education about the disease to both the patient and family. Nurses also set goals for each patient and assessed for lifestyle modifications. This study not only focused on the number of hospital readmissions, but it also focused on the financial impact that this issue had on the hospital. The results of this trial showed that the readmission rate dropped by 48% after the nurse home visits. Also, there were two deaths in the control group and zero deaths in the intervention group. Moreover, there was an increase in the hospital budget of about $227 per Medicare patient. Additionally, the American Heart Association (2010), states that home nurse visits after discharge can greatly benefit patients who suffer from heart failure. They state that at least one 6 SYNTHESIS PAPER hour of patient education performed during this visits has resulted in better outcomes for both the patient and the hospital. Synthesis Several studies have shown that home nurse interventions reduce the number of readmissions among patients with heart failure. Brotons et al. (2009) proved that once a month visit to these patients reduces the amount of readmissions. Jorstad and Alings (2013) found that nurse visits improved the quality of lives on patients diagnosed with acute coronary syndrome. Also, Brett et al. (2011) showed that nurse follow-up for 3 months reduced readmission rates as well. The results of these studies showed that these nurse visits had a positive impact on the hospital readmission rates. The nurses involved in these studies focused on providing patient education as well as assessing signs and symptoms of this condition. They also focused on promoting a healthier lifestyle on patients who were obese or smokers. Each patient had the chance to be educated and ask questions about the management of heart failure at the comfort of their home. Moreover, the nurses on these studies were able to provide more individualized care to these patients and provide them with more detailed information. The length of these studies ranged from 3 months to 1 year follow up. See Table 1 for a summary of these three randomized controlled trials along with the results of each trial. Clinical Recommendations The American Heart Association (2010) recommends that patients with heart failure take their medications as prescribed, reduce sodium intake to 2 grams per day, monitor their weight daily, and quit smoking. They encourage nurses to start patient education as soon as patients arrive to the emergency department. The nurse involved in patient’s education should identify obstacles that prevent the patient from managing this condition such as motivation, cognitive 7 SYNTHESIS PAPER deficits, economic status, education level, and social support. Such obstacles result in hospital readmissions. In addition, they recommend that patients with heart failure should be provided with follow up appointments by a nurse either by phone or at home to reduce readmissions. Such measures have been effective in reducing readmissions. This recommendation has been proven by the three randomized control trials mentioned before. Therefore, Florida Hospital Tampa should provide patients with nurse home visits biweekly for at least three months to reduce the amount of readmissions. During these visits, the nurse should provide education about the management of heart failure to both the patient and the family. The nurse should evaluate the health status of each patient and remind him/her about the importance of reporting to their physician weight gain of 2-5 pounds weekly along with shortness of breath while resting, using more pillows to sleep, developing a dry cough, and swelling of the belly and ankles. Conclusion In conclusion, many hospitals are working hard to lower readmission rates on patients with heart failure. This issue not only affects the patients, but also the hospital itself. As studies have shown, patient education alone is not helping decrease the number of hospital readmissions. Nursing interventions along with usual care following discharge has proven to reduce the readmission rate. During home nurse visits, patients benefit from both assessment and education. Nurses also have to opportunity to check the status of this condition before an emergency takes place. This statement has not only been proven by different randomized control trials, but it has been recommended by the American Heart Association also. 8 SYNTHESIS PAPER Table 1 Literature Review Reference Brotons, C., Falces, C., Alegre, J., Ballarin, E., Casanovas, J., Cata, T.,… Vidal, X. (2009). Randomized clinical trial of the effectiveness of a home based intervention in patients with heart failure: The IC-DOM study. Revista Espanola de Cardiologia, 64(4), 400-408 Jorstad, H., Clemens, B., & Alings, M. (2013). Effect of a nurse-coordinated prevention programme on cardiovascular risk after an acute coronary syndrome: Main results of the RESPONSE randomized trial. Heart 99(19), 14211430.doi 10.1136/heartjhl-2013-303989 Aims Design and Measures To determine Randomized if home controlled nurse visits trial decrease the amount of Measures: hospital Evaluate if readmission. nurse home visits after discharge decrease the amount of hospital readmission rate. Evaluate effects of home nursing interventions among patients with acute coronary syndrome. Stauffer, B., Fullerton, C., Fleming Test if N.,Ogola, G., Herrin, J., Pamala, S., & nursing Ballard, D. (2011). Effectiveness and cost home visits Randomized controlled trial Measures: evaluate if home nurse visits would decrease the amount of readmissions on patients diagnosed with acute coronary syndrome. Randomized controlled trial Sample 283 participants divided between the intervention group and the control group. Participants in the intervention group received home care by a nurse, and those in the control group received usual care with their physician. 754 patients involved in the trial. Those in the intervention group received patient education and assessment during the home nurse visits. Participants who received Outcomes / statistics Less hospital readmissions in the intervention group than in the control group. P>.001 Less hospital readmissions in the intervention group and improved lifestyle P>.0021 Reduced hospital readmission 9 SYNTHESIS PAPER of a transitional care program for heart failure: A prospective study with concurrent controls. JAMA Internal Medicine 171 (14), 12381243.doi10.1001/archinternmed.2011.27 4 decrease the readmission rate Measures: Evaluate if there is a reduction in the readmission rate in patients with heart failure. nursing care follow up had lower readmission rate than those who did not. in patients with heart failure by 48%. 10 SYNTHESIS PAPER References American Heart Association. (2010). Acute heart failure syndromes: Emergency department presentation, treatment, anddisposition: Current approaches and future aims a scientific statement from the American Heart Association. Circulation, 122, 1975-1996. doi 10.1161/CIR.0b013e3181f9a223 Brotons, C., Falces, C., Alegre, J., Ballarin, E., Casanovas, J., Cata, T.,… Vidal, X. (2009). Randomized clinical trial of the effectiveness of a home based intervention in patients with heart failure: The IC-DOM study. Revista Espanola de Cardiologia, 64(4), 400-408. Jorstad, H., Clemens, B., & Alings, M. (2013). Effect of a nurse-coordinated prevention programme on cardiovascular risk after an acute coronary syndrome: Main results of the RESPONSE randomized trial. Heart 99(19), 1421-1430.doi 10.1136/heartjhl-2013-303989 Stauffer, B., Fullerton, C., Fleming N., Ogola, G., Herrin, J., Pamala, S., & Ballard, D. (2011). Effectiveness and cost of a transitional care program for heart failure: A prospective study with concurrent controls. JAMA Internal Medicine 171 (14), 1238-1243. doi 10.1001/archinternmed.2011.274