Nurse-Led Heart Failure Follow-Up in Primary Care in Sweden

Nurses' experiences of continuity of care for patients with heart failure: A thematic analysis

AIMS AND OBJECTIVES

This study aimed to describe nurses' experiences of continuity of care for patients with heart failure.

BACKGROUND

Heart failure is a life-influencing condition that causes varying care needs over time with risks of fragmentation. Nurses play an important role in caring for patients with heart failure. However, nurses' experiences of continuity of care seem to be less explored in this context.

DESIGN

A qualitative study with a descriptive design.

METHODS

Four focus groups were chosen to collect the data, and the analysis was made by using a method for thematic analysis. A purposeful sampling of nurses (n = 14) with experiences from hospital-connected heart failure clinics, primary healthcare centres and municipal home healthcare settings was recruited. The COREQ checklist was used in this study.

RESULTS

The nurses' experiences of continuity of care for patients with heart failure were described in four themes: access and flexibility, responsibility and transparency, trustful and caring relationships and communication and collaboration.

CONCLUSIONS

The results indicate that nurses have an excellent position to act as the "hub" in caring for patients with heart failure, but they need to have the possibility of networking and establishing trusting relationships with their colleagues. From the nurses' point of view, mutual trust between the nurse, the patient and the patient's next of kin is crucial for promoting and maintaining continuity of care in patients with heart failure.

RELEVANCE TO CLINICAL PRACTICE

To promote continuity of care for patients with heart failure, nurses expressed the necessity of establishing trusting relationships in a continuity-promoting organisation with seamless coordination. Nurses can be the "hub" supporting a person-centred care approach based on the patients' needs. There seems to be a need for better collaboration with common guidelines across and within primary healthcare centres, hospital-connected heart failure clinics and municipal home healthcare settings.

Reorganization of heart failure management and improved outcome - the 4D HF Project

OBJECTIVES

Heart failure (HF) management is suboptimal in Sweden despite available evidence-based guidelines. To improve HF treatment, a comprehensive HF management program (4D project) was implemented in the Stockholm County (>2.1 million inhabitants). Design. A standardized care program centralized at five hospital-based HF clinics was implemented in 2014-2017. We registered from 2012 to 2017: (1) numbers of referrals and visits to HF clinics, (2) numbers of hospital admitted patients per million inhabitants, (3) dispensed HF medications after admission, and (4) covariate-adjusted 1-year all-cause mortality or HF readmission. Results. Yearly visits to the five HF outpatient clinics increased 3.4 times from 3,372 to 11,527. Dispensed HF drug prescriptions increased, in particular, for readmitted patients, compared to 2012 (p<.0001). Total number of hospital admitted HF patients as well as new-onset or readmitted HF patients decreased by 16, 13, and 20%, respectively (p < .0001). The combined 1-year mortality or HF readmission over the period was 48% (n = 17,124/35,880) and improved per year (HR 0.98 [0.97-0.99], p < .001) from 2012. Conclusion. A comprehensive standardized care HF management program including expanded HF clinics was associated with improved evidence-based medication, reduced HF hospitalization, and improvement of the combined outcome of 1-year mortality or HF readmission in Stockholm.

Introducing nurse-led heart failure clinics in Swedish primary care settings

AIM

According to clinical guidelines, it is recommended that patients with heart failure (HF) receive structured multidisciplinary care at nurse-led HF clinics in order to optimise treatment and avoid preventable readmissions. Today, there are HF clinics with specialist-trained nurses at almost all Swedish hospitals, but HF clinics remain scarce in primary care (PC). The aim of this study was two-fold: firstly, to evaluate the effects of systematically implementing nurse-led HF clinics in PC settings with regard to hospital healthcare utilisation and evidence-based HF treatment, and secondly to explore patients' experiences of HF clinics in PC.

METHODS AND RESULTS

The study had a pre-post design. Annual measurement were done between 2010-2017 regarding in-hospital healthcare consumption and medical treatment. Data from 2011-2017 after the implementation of HF clinics in PC in one county council Sweden were compared with baseline data collected before the implementation in 2010. The implementation of HF clinics in PC significantly reduced the number of HF-related hospital admissions by 27% (P < 0.001), HF hospital days by 27.3% (P < 0.001) and HF emergency room visits by 24% (P < 0.001). Further, patients were to a higher extent medically treated according to guidelines and satisfied with the care they received at the PC HF clinic.

CONCLUSION

Nurse-led HF clinics in PC seem to be effective in reducing the need for in-hospital care and provide high quality person-centred care.

Heart Failure Patients' Perceptions of Received and Wanted Information: A Cross-Sectional Study

This study aimed to investigate heart failure patients' perceptions of received and wanted information and to identify differences regarding received and wanted information in relation to sociodemographic variables. A cross-sectional descriptive design was used. Patients with heart failure ( n = 192) were recruited from six primary health care centers in Sweden. Data were collected by a postal questionnaire. A majority of the respondents had received information about the condition and the medication. Within primary health care, most respondents had been informed about medication. The respondents wanted more information about continued care and treatment, medication, and the condition. There were significant differences between sociodemographic groups concerning what information they wanted. Clinical nurses can support patients with heart failure by using evidence-based methods that strengthen the patients' self-efficacy and by individualized information that increases patients' knowledge and improves their self-care behaviors. Future studies are needed to identify informational needs of particular fragile groups of patients.

Adherence to guidelines in patients with chronic heart failure in primary health care

OBJECTIVE

To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care.

DESIGN

A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire.

SETTING

Three primary health care centres in Sweden.

SUBJECTS

Patients with a CHF diagnosis registered in their medical record.

MAIN OUTCOME MEASURES

Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9).

RESULTS

The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour.

CONCLUSION

Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour.

The effect on patient outcomes of a nursing care and follow-up program for patients with heart failure: A randomized controlled trial

BACKGROUND

Heart failure is associated with exacerbated symptoms such as dyspnea and edema and results in frequent hospitalization and a poor quality of life. With the adoption of a comprehensive nursing care and follow-up program, patients with heart failure may exhibit improvements in their self-care capabilities and their hospitalizations may be reduced.

OBJECTIVE

The purpose of this study was to examine the effect of a nursing care and follow-up program for patients with heart failure on self-care, quality of life, and rehospitalization.

DESIGN AND SETTING

This research was conducted as a single-center, single-blind, randomized controlled study at the heart failure outpatient clinic of a university hospital in Turkey.

PARTICIPANTS

A total of 90 patients with heart failure were randomly assigned into either the specialized nursing care group (n=45) or the control group (n=45).

METHODS

The nursing care and follow-up program applied in the intervention group was based on the Theory of Heart Failure Self-care. Data were collected at the beginning of the trial, and at three and six months after the study commenced. Self-care of the patients was assessed by the Self-Care of Heart Failure Index. Quality of life was assessed with the "Left Ventricular Dysfunction Scale". Rehospitalization was evaluated based on information provided by the patients or by hospital records.

RESULTS

A statistically significant difference was found between the intervention and control group with respect to the self-care and quality of life scores at both three and six months. While the intervention group experienced fewer rehospitalizations at three months, no significant differences were found at six months.

CONCLUSION

The results obtained in this study show that the nursing care and follow-up program implemented for patients with heart failure improved self-care and quality of life. Although there were no significant differences between the groups at six months, fewer rehospitalizations in the intervention group was considered to be an important result.

Registered Nurses' Perceptions about the Situation of Family Caregivers to Patients with Heart Failure - A Focus Group Interview Study

INTRODUCTION

Heart failure is a growing public health problem associated with poor quality of life and significant morbidity and mortality. The majority of heart failure care is provided by family caregivers, and is associated with caregiver burden and reduced quality of life. Research emphasizes that future nursing interventions should recognize the importance of involving family caregivers to achieve optimal outcomes.

AIMS

The aims of this study are to explore registered nurses' perceptions about the situation of family caregivers to patients with heart failure, and registered nurses' interventions, in order to improve family caregivers' situation.

METHODS

The study has a qualitative design with an inductive approach. Six focus group interviews were held with 23 registered nurses in three hospitals and three primary health care centres. Data were analysed using qualitative content analysis.

RESULTS

Two content areas were identified by the a priori study aims. Four categories and nine sub-categories emerged in the analysis process. The content area "Family caregivers' situation" includes two categories: "To be unburdened" and "To comprehend the heart failure condition and its consequences". The content area "Interventions to improve family caregivers' situation" includes two categories: "Individualized support and information" and "Bridging contact".

CONCLUSIONS

Registered nurses perceive family caregivers' situation as burdensome, characterized by worry and uncertainty. In the PHCCs, the continuity and security of an RN as a permanent health care contact was considered an important and sustainable intervention to better care for family caregivers' worry and uncertainty. In the nurse-led heart failure clinics in hospitals, registered nurses can provide family caregivers with the opportunity of involvement in their relative's health care and address congruence and relationship quality within the family through the use of "Shared care" and or Family-centred care. Registered nurses consider it necessary to have a coordinated individual care plan as a basis for collaboration between the county council and the municipality.

Patient-Nurse Communication about Prognosis and End-of-Life Care

BACKGROUND

Although several studies advise that discussions about prognosis and end-of-life care should be held throughout the whole heart failure (HF) trajectory, data is lacking on the prevalence and practice of such discussions in HF care.

OBJECTIVE

The study objective was to explore how often and why HF nurses in outpatient clinics discuss prognosis and end-of-life care in the context of patient education.

METHODS

This was a descriptive and comparative study. Participants were HF nurses from Swedish and Dutch HF outpatient clinics. Measurements were taken via a survey for both quantitative and qualitative data. Additional data was collected via open-ended questions and analyzed with content analysis.

RESULTS

Two hundred seventy-nine nurses registered 1809 patient conversations using a checklist. Prognosis and end-of-life care were among the least frequently discussed topics, whereas symptoms of HF was discussed most often. Prognosis was discussed with 687 patients (38%), and end-of-life care was discussed with 179 patients (10%). Prognosis and end-of-life care were discussed more frequently in The Netherlands than in Sweden (41% versus 34%, p<0.001, 13% versus 4%, p<0.001). The nurses did not always recognize prognosis and end-of-life care discussions as a part of their professional role.

CONCLUSIONS

Currently, patient-nurse communication about prognosis and end-of-life care does not seem to be routine in patient education in HF clinics, and these discussions could be included more often. The reasons for nurses to discuss these topics were related to clinical routines, the patient's situation, and professional responsibilities. To improve future care, communication with patients needs to be further developed.

Living with heart failure without realising: a qualitative patient study

Heart failure is an important problem in Swedish primary healthcare as in the U.K. In spite of that little is known about how people with heart failure experience support from primary healthcare. This paper investigates how people with heartfailure experience support in primary healthcare. Semi structured interviews were conducted with five men and five women, born 1922-1951. The interviews were analyzed with qualitative content analysis in accordance with Graneheim and Lundman (2004). The participants experienced they had not received information about their diagnosis or about the cause of their condition. They had not been informed they had heart failure. Instead the participants believed their symptoms were caused by age, thus being part of normal ageing. They did not experience they needed care or support to cope with illness or disease. Instead their main needs for support in daily life concerned help with practical matters.There is a risk primary healthcare abandons people with heart failure meaning the patients are forced to develop strategies on their own in order to manage symptoms. When inadequately informed there is also a risk they make up their own explanations signifying possible difficulties to handle their health situation.

Differences between heart failure clinics and primary health care

There is a paucity of knowledge concerning how people with heart failure experience differences between specialised heart failure clinics and primary healthcare in Sweden. This study aimed to describe differences regarding information and follow-up in heart failure clinics and primary healthcare. The study was conducted in Sweden in 2011. Four people (three men, one woman; aged 60 to 84) with heart failure (NYHA II) were interviewed. The interviews were analysed with qualitative content analysis. The findings revealed after referral from the heart failure clinic to primary healthcare, follow-ups were omitted. Still, the patients needed care, support and information. The findings are illuminated in four themes. The patients' varying and individual needs can be difficult to recognise and manage unless they are followed-up from either HFC or PHC on a regular basis.

Components of heart failure management in home care; a literature review

BACKGROUND

Patients with heart failure (HF) need long-term and complex care delivered by healthcare professionals in primary and secondary care. Although guidelines on optimal HF care exist, no specific description of components that are applied for optimal HF care at home exist. The objective of this review was to describe which components of HF (home) care are found in research studies addressing homecare interventions in the HF population.

METHODS

The Pubmed, Embase, Cinahl, and Cochrane databases were searched using HF-, homecare services-, and clinical trial-related search terms.

RESULTS

The literature search identified 703 potentially relevant publications, out of which 70 articles were included. All articles described interventions with two or more of the following components: multidisciplinary team, continuity of care and care plans, optimized treatment according to guidelines, educational and counselling of patients and caregivers, and increased accessibility to care. Most studies (n=65, 93%) tested interventions with three components or more and 20 studies (29%) used interventions including all five components.

CONCLUSIONS

There a several studies on HF care at home, testing interventions with a variety in number of components. Comparing the results to current standards, aspects such as collaboration between primary care and hospital care, titration of medication, and patient education can be improved.

Primary health care resources for rehabilitation and secondary prevention after myocardial infarction - a questionnaire survey

BACKGROUND

During the first year after a cardiac event, many patients are offered participation in a cardiac rehabilitation programme, after which the patients are often not given the opportunity to continue to attend rehabilitation and secondary prevention programmes.

AIM

This study describes the primary health care centres' (PHCC) resources regarding cardiac rehabilitation/secondary prevention programmes for coronary heart disease (CHD) patients in a southern Swedish region.

METHOD

A questionnaire containing 26 dichotomous or multiple choice questions was sent to the responsible manager of all 137 public and private PHCCs in Region Skåne. Questionnaires from 91 (66%) of the PHCCs were completed and returned.

RESULT

Few nurses at the PHCCs had special training regarding CHD (10%), cardiac rehabilitation (8%) or heart failure (32%). Twenty-one per cent of the physicians had special training regarding CHD. One third of the PHCCs did not offer long-term secondary prevention programmes, and few (6%) had any routines for offering socio-economic support to CHD patients. Comparison of private and public PHCCs showed that the private centres could not offer a physiotherapist (61 vs. 84%) or dietician (32 vs. 73%; p = 0.03) to the same extension as the public ones. Furthermore, the majority (91%) of PHCCs had no cooperation with patient organizations.

CONCLUSIONS

The PHCCs need to improve the strategies and long-term rehabilitation programmes. Furthermore, they need to focus on education programme for the staff. The result revealed that the PHCCs lack resources, strategies and long-term care programmes for CHD patients.