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Running head: SYNTHESIS PAPER
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Synthesis paper
Carmen Valdez
University of South Florida
NUR 4169C, Semester 3
Professor Melissa Shelton
October 20, 2013
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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.
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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
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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
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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
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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
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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.
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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
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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
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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%.
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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