Impact of the Problem on the Congestive Heart Failure Patients

Impact of the Problem on the Patient

Congestive heart failure patients are at higher risk for readmission into the hospital because of inadequate education in self-care. And with readmission to hospital due to lack of knowledge, patients with CHF tend to develop other co-morbidities which will lead to patients requiring a higher level of treatment and monitoring. The quality of live for these CHF patients will a deteriorates leading to more complicated treatments, and patients and their families incurring costly medical expenses. Some of the complications of CHF on these patients depend on which side of the heart is affected. Patients who suffer right sided HF sometimes will experience increase in weight gain edema, and tachycardia. As for left sided HF patients some will show restlessness with confusion, tachycardia, and shortness of breath. With all these complications that a company’s HF takes a toll on the patients’ physical, emotional, and financial well-being. The Families of these CHF patients they too bear the same weight of emotions, physical financial and relationship distress. Education of the patients and their families on the treatment, management, and lifestyle changes that will help patients from being readmitted back to hospital due to CHF.

Impact of the Problem on the Organization

CHF patients being readmitted back in hospital within 30 days of discharge has increased and it is a huge expense to the health facilities has the insurance companies will not reimburse the hospitals. Hospitals reputation are also brought into question, also the doctors and nurses are affected because they feel like they did an inadequate job in educating the patients in steps and changes needed to reduce the patient readmission within a short time from discharge. The cost of medications, treatment, and stay falls on the hospitals, and so the hospitals needs to give a good discharge education to these CHF patients on steps, signs and symptoms and also changes like diet and exercise that patients needs to incorporate to stay healthy.

Identify the PICO components

P – CHF patient at risk for readmission

I – Education in CHF self-management

C – No education in CHF self-management

O – Reduce readmission rates

Evidence Based Practice Question

In patients with CHF will education on CHF self-management reduce readmission rates as compared to no education on CHF self-management?

Research Article: Çavuşoğlu, Y. et al. (2017). Post-discharge heart failure monitoring program in Turkey: Hit-PoinT. Anatol Journal of Cardiology, 17: 107-12

Background Introduction 

A well-written background is supposed to support the research question and to help the readers ascertain whether the authors have a foundational understanding of the research issue being examined.  It also provides the study with context of the research prompting readers to read the information presented in the rest of the paper. These criteria have been met in “Post-discharge heart failure monitoring program in Turkey: Hit-PoinT.” The background is well written and engaging. The introduction is clearly linked to the research issue being investigated. The purpose and the rationale for conducting the study are cleared stated. Relevant and important studies are used to identify and justify the need to conduct this study. The gaps in the body of current knowledge in the management of heart failure that needed to be addressed are clearly identified. The authors noted that disease management programs for treating individuals with HF have been promoted by society guidelines for the purpose of improving patient compliance and reducing hospitalizations. There are many varied HF management programs, however, and most of them are expensive and impractical to employ in various areas. The aim of the study is clearly stated and relevant to the PICO question. Literature is adequately cited to support the need to conduct the study and the sources used are relevant and current. The objective was to assess the efficacy and feasibility of an enhanced heart failure (HF) education with a 6-month telephone follow- up program in post-discharge ambulatory HF patients. Therefore, this section has met the criteria as far as background is concerned.

Methodology

The methodological approach used has been clearly stated. The study indicates that is a randomized controlled trial (RCT) study. The Hit Point trial was a multicenter; randomized, controlled trial of enhanced HF education with a 6-month phone follow-up program (EHFP) vs routine care (RC) (Çavuşoğlu et al. 2017). The study protocol lays out the procedure for participant recruitment and selection. However, the assumptions and rationale underpinning the methodology chosen are not discussed. Recruitment methods, inclusion and exclusion criteria, selection of intervention and control are all captured in the study. Participants aged 18 years and above were recruited between March 2010 and April 2013 at 10 cardiology centers in various geographical areas.  The inclusion and exclusion criteria are described. Inclusion criteria used included patients who carried the diagnosis of HF secondary to systolic dysfunction, had been hospitalized for HF within six months of randomization, and had symptoms despite optimal medical therapy (Çavuşoğlu et al. 2017). Education included information on the adherence to treatment, symptoms recognition, diet and fluid intake, weight monitoring, activity, exercise training and when to contact cardiologist. Participants were contacted by phone at 1, 3 and 6-month interval. The primary study endpoint was cardio-vascular death. Thus there is a follow up of the treatment along with the intermittently assessment of outcomes.

Two nurses and two cardiologists from each center were recruited and trained about HF patient education and the study protocol. After receiving training, they implemented one session of HF education at randomization (Çavuşoğlu et al. 2017). The experiment group received education by cardiologist and nurse on management of HS during discharge. The session took at least one hour. HF booklets were also issued to the EHFP group.

Methods of data collection are not clearly described. Data collection focused on primary and secondary endpoints including cardiovascular mortality, all-cause hospitalization, and emergency room visits, NYHA functional classification and all-cause mortality and the rate of hospitalization for heart failure after six months. Tools used to take measures for these end-points are not stated and described. Tools for measuring outcomes do influence the validity of the results. Validated and standard tools are associated with increased reliability and internal validity of the study results.

The study protocol is comprehensive and includes important details of the study design. Baseline measurements are described and listed Baseline characteristics for both EHFP and the RC groups are the same except for hyperlipidemia rate. Hyperlipidemia rate may swe4rve as a confounding variable. The subjects have been randomized into experimental group and control group. However, researchers and participants are not blinded. I does not consider that blinding of researchers and participants was possible for this kind of intervention, however, thereby causing subjective biases. The blinding of participants may not be possible where the participant’s active participation is required. At least the nurses and cardiologists involved in collecting should be blinded.  Blinding and randomization in randomized controlled trials are critical for ensuring high quality outcomes. In the current study, chances are high that the researcher would influence the study outcome in the absence of blinding. The participant may also be influenced Blinding is meant to avoid selection bias and increase objectivity.

The study also failed to assess changes in quality of life, number of ambulatory visits and adherence to treatment. This makes it hard to appraise the effect of EHFP. The number of dropouts is not stated or described.

Level of Evidence

The level of evidence is not stated in the study. Many RCT studies often state the level of evidence for their studies. The level of evidence for this RCT is considered to be level II due to it small RCT and unclear results. In therapeutic studies, this may be considered level 1B (individual RCTs with narrow confidence interval).  Any evidence obtained from at least one well designed RCT fall under level II.

Data Analysis

The study used statistical analysis methods to extract information. For example, the study used standard deviation, mean and cross-tabulation to analyze collected data. The data analysis methods are appropriate given that this is quantitative research

Ethical Considerations

The researchers took necessary steps to mitigate any ethical concerns that might arise. The study recruited and obtained consent of participants as per the study protocol approved by the ethics committee (Çavuşoğlu et al. 2017). The study followed the guidelines of the Declaration of Helsinki to the letter. The participants provided written informed consent. Ethical consideration in RCT is important because it involves treatment intervention of subjects.

Quality Rating

GRADE assessment rate the evidence of EHFP as moderate quality because of suspicion of subjective bias and failure to describe dropout rate. The researchers are moderately confident in the effect estimate. Indeed, the true effect is likely to be close to the estimate of the effect, however, there is a likelihood that it is considerably different. Quality of evidence is rated using different guidelines. However, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) is the recommended method of rating the quality of evidence. According to GRADE, evidence-based on RCT starts as high quality evidence. However, this quality may be lowered due to study limitations (absence of blinding and imprecision). This is definitely moderate quality. Future research is likely to affect our confidence in the effect of the estimate.

When rating the quality of evidence for RCT, one must consider randomization, blinding, description of blinding and randomization process, description of the dropout rate, confidence intervals between estimates. This study never blinded both the researchers and subjects. The process of randomization is not only described the number of participants who dropped out are not indicated or described. The study also never performed power analysis. .

Analysis of the Results / Conclusions

The results are well analyzed and its figures presented in a graphical presentation for easy understanding. Of the 248 randomized participants, 73% were men with NYHA class II-IV HF symptoms. Baseline characteristics were similar for both the EHFP group and the control. The results found that six-month cardiovascular mortality to be remarkably higher in the control (p<0.05). Similarly, at baseline 60 percent of patients in EHFP and 61 percent in the control belonged to NYHA Class III and IV; at 6-month follow up only 12 percent in EHFP and 32 percent in the control belonged to NYHA Class III and IV. The EHFP had 0.58 +/- 0.91 mean number of hospitalization while the control had 0.64 +/-1.05. EHFP had 0.84+/- the mean number of emergency room visits while the control had 21+/-47 at 6-monthfollow-up (p<0.05) (Çavuşoğlu et al. 2017).

The study results indicate that enhanced education using a phone follow-up considerably decreased cardiovascular deaths and reduced number of ER visits in the 6-month period after discharge in HF patients.

The strength of this study is that participants were recruited at 10 different centers. This means that the findings are generalizable. The limitation is the failure to blind the participants and researchers leading to selection bias.

Non-Research Article Dolansky, M.A., Capone, L., Leister, E., & Boxer, R.B. Targeting heart failure rehospitalizations in a skilled nursing facility: A case report. Heart & Lung, 42; 392-396

Background Introduction

The existing clinical practice guidelines for management of heart failure in long-term care are based on clinical experience. Some of these guidelines are developed for varied settings. As a result, there is limited data showing the best approach to manage patients with HF in skilled nursing facilities for the purpose of improving patient outcomes. Furthermore, all-cause re-hospitalizations from skilled nursing facilities have doubled in recent times. Re-hospitalizations has been as high as 58% for HF patients. Determining medical diagnosis and capturing factors associated with re-hospitalization at the time of transfer to a SNF is critical in understanding patterns and opportunities for improvement. Although this information could be captured in patient registry, there is paucity of studies describing its usage to facilitate the decrease of all-cause re-hospitalizations from SNFs.  This case report describes the lessons drawn from a SNF that targeted the reduction of re-hospitalization for HF patients. The background is well-written and organized. Important and relevant studies are used to justify the need to conduct this case report. The aim of the state is clearly stated. However, the introductory part combined with the literature review section. The authors would have done better writing them separately.

Type of Evidence

Evidence-based case report

Level of Evidence

Case reports are level V. this level is considered very weak evidence

Quality Rating
This study can be rated as low quality: further research is likely to have an impact on the confidence in the estimate of effect to change the estimate

Author’s Recommendations

The recommendations are not clearly stated in the study. The author seemed to suggest or imply for

• Implementation of electronic medical record to support efforts in SNFs
• Establishment of HF diagnosis at SNF admission
• Improve HF assessment by training unlicensed staff about the value of observation and objective vital sign skill
• Implementing re-hospitalization risk tool to identify at risk patients
• Targeting vigilant assessment of a declining condition in patients with a primary HF diagnosis during the first 7 days of SNF care
• Creating a quality improvement learning environment by educating their staff on QI methods

Recommended Practice Change

• To meet the needs of patients with HF, enhanced heart failure (HF) education program is recommended. Çavuşoğlu et al (2017) have demonstrated the beneficial effect of EHFP and follow up program on morbidity and mortality in patients with HF. EHFP is associated with reduced cardiovascular deaths and number of ER visits. Because the current evidence is derived from a RCT with important limitations, it should be used with caution.
• Use of patient registry to guide quality improvement initiatives. Dolansky, Capone, Leister and Boxer (2016) reported that the use of patient registry to track and understand indicators of re-hospitalizations could result in better outcomes.
• In respect to nursing, nurses play a critical role in patient education, particularly discharge instructions to ensure adherence to EHFP. Educating patients about proper management of HF will lead to reduced HF related morbidity and mortality and reduction in re-hospitalization and improve HF knowledge.

Key Stakeholders

• They want to know what ROLE each stakeholder played in helping you develop your policy (practice change). Use verbiage like this:

• The first key stakeholder is the cardiologist and they are involved in the practice change because their role will be to educate patients on heart failure management. The second key stakeholder is the nurse and they are involved in the practice change because their role will be to educate patients on heart failure management. The third key stakeholder is the patient and they are involved in the practice change because their role will be to learn and improve their HF knowledge and self-care

Barrier to Implementation

• Lack of time
• Participant acceptance of this intervention
• Lack of resources
• Participant adherence to this intervention

Strategy to Overcome the Implementation Barrier

• Engage relevant stakeholders to build trust
• Seek administrative support from the organization because organizational culture play an important role in supporting or rejecting the intervention
• Allocating resources for this intervention
• Articulate how the intervention could serve as a tool to reduce all-cause mortality and all-cause re-hospitalization

Indicator to Measure the Outcome

The indicators to measure the outcomes include the following:

• Total number of deaths at the end of study follow up in each arm of study;
• Total number of all-cause hospitalizations estimated as the percent of participants readmitted to hospital at least once during the follow-up period;
• Proportion of patient that adherence to the EHFP intervention, percent of patients who accept the intervention by participants;
• Improved HF knowledge and self-care as appraised by validated tools
• Proportion of participants re-hospitalized at least once during the follow-up because of HF.

References

Çavuşoğlu, Y. et al. (2017). Post-discharge heart failure monitoring program in Turkey: Hit-PoinT. Anatol Journal of Cardiology, 17: 107-12

Dolansky, M.A., Capone, L., Leister, E., & Boxer, R.B. Targeting heart failure rehospitalizations in a skilled nursing facility: A case report. Heart & Lung, 42; 392-396