A nurse practitioner-led effort to reduce 30-day heart failure readmissions

Home intravenous diuretic administration for heart failure management: A scoping review

BACKGROUND

Heart failure (HF) significantly impacts healthcare systems due to high rates of hospital bed utilization and readmission rates. Chronic HF often leads to frequent hospitalizations due to recurrent exacerbations and a decline in patient health status. Intravenous (IV) diuretic administration is essential for treating worsening HF. Emerging strategies include home-based IV diuretic therapy administration; however, limited practical implementation guidance is available. This scoping review aims to summarize the literature on home IV diuretic administration for HF patients, focusing on the interventions' characteristics, and facilitators and barriers to its implementation.

METHODS

This review followed the scoping review framework proposed by Arksey and O'Malley and PRIMSA-ScR. A comprehensive search was conducted across six databases (CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsychINFO and Scopus) and grey literature to identify English studies from inception to April 13, 2024. Two independent reviewers screened articles and resources for inclusion and data was extracted using a form created by the authors in Covidence.

RESULTS

The search yielded 2,049 results, with nine studies meeting the inclusion criteria. Studies varied in design, including feasibility, pilot, observational, and pre/post-intervention evaluations. The majority were conducted in European countries, with sample sizes ranging from 12 to 96 patients receiving home IV diuretics for HF. Key implementation challenges include appropriate patient selection, IV cannulation competency of healthcare providers, and multi-disciplinary and multi-agency collaboration.

CONCLUSIONS

Evidence on home IV diuretic administration practices for HF management remains limited. However, this scoping review suggests that commonalities across studies could form the basis for developing standard protocols in outpatient settings. Despite the lack of formal evidence-based guidelines, the findings also suggest that tailored, community-specific approaches and safe infusion guidance documents could enhance the efficacy and scalability of home IV diuretic therapy. Future research should focus on refining these strategies and exploring diuretic escalation methods beyond traditional acute care administration to optimize patient outcomes.

Heart failure self-management: a scoping review of interventions implemented by allied health professionals

BACKGROUND

Heart failure (HF) is typically managed using both medical and patient self-management interventions. Individuals with HF often have frequent readmissions to hospital for medical management. Effective self-management can help to reduce the exacerbation of HF symptoms and the frequency of readmissions.

METHODS

A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) guidelines was conducted to identify literature on the interventions used by allied health professionals to promote HF self-management. A search strategy was implemented, and articles were reviewed by two independent reviewers.

RESULTS

Twenty articles met the inclusion criteria. Articles included interventions from physical therapy, nutrition, social work, and occupational therapy, as well as other health professions in team-based programs. The most common interventions were verbal education, textual information, monitoring resources, and skills practice. Interventions addressed diet/fluid control, exercise and activity, symptom monitoring, medication management, cardiovascular disease knowledge, and mental health. Many interventions were theory informed.

CONCLUSION

There is nascent evidence that interventions promoting HF self-management positively impact health and quality of life outcomes. HF self-management is multi-faceted and requires interprofessional collaboration. Further work is warranted exploring the impact of theory-informed interventions, and the effectiveness of interventions on self-management competence and desired health outcomes.

Exploring heart failure nurse practitioner outcome measures: a scoping review

AIMS

Clinical guidelines recommend people with heart failure are managed within a multidisciplinary team to receive optimal evidence-based management of the syndrome. There is increasing evidence that Nurse Practitioners (NP) in heart failure demonstrate positive patient outcomes. However, their roles as key stakeholders in a multidisciplinary heart failure team are not clearly defined. The aim of the review was to explore the literature related to NP-sensitive outcomes in heart failure.

METHODS AND RESULTS

A scoping review was conducted according to accepted guidelines using the Joanna Briggs Institute framework for conducting a scoping review, to identify the literature that related to NP-sensitive outcomes in heart failure management. Sixteen texts were selected for data extraction and analysis. The most common outcome measures reported were readmission rates, self-care measurement scales, functional status scores, quality of life measurements, and medication optimization outcomes. No two studies collected or reported on the same outcome measurements.

CONCLUSION

This review highlights that the reporting of heart failure (HF) NP outcome indicators was inconsistent and disparate across the literature. The outcome measures reported were not exclusive to NP interventions. Nurse Practitioner roles are not clearly defined, and resulting outcomes from care are difficult to characterize. Standardized NP-specific outcome measures would serve to highlight the effectiveness of the role in a multidisciplinary HF team.

Key Factors to Consider When Implementing an Advanced Practice Registered Nurse-Led Heart Failure Clinic

Advanced practice registered nurses (APRNs) such as clinical nurse specialists and nurse practitioners excel at chronic disease management. Development of an APRN-led heart failure (HF) clinic is an ideal way to manage complex HF patients. However, there are important factors to consider when implementing an APRN-led HF clinic. The purpose of this paper is to provide a consolidation of recommendations to consider when developing and implementing an APRN-led HF clinic. A review of applicable literature within the last 10 years was conducted to determine the key factors to be considered when developing organizational structures and processes for an APRN-led HF clinic. The increasing need for primary care and internal medicine providers supports using APRNs to fill the gap and provide disease management for HF patients. Also, APRNs can impact the overall costs of HF treatment by optimizing postdischarge care and preventing hospitalizations and readmissions. Multiple studies supported implementation of APRN-led HF clinics for disease management to provide complex treatment strategies and comprehensive care to these patients.

Broadening Heart Failure Care Beyond Cardiology: Challenges and Successes Within the Landscape of Multidisciplinary Heart Failure Care

PURPOSE OF REVIEW

Heart failure (HF) is a growing public health concern that impairs the quality of life and is associated with significant mortality. As the prevalence of heart failure increases, multidisciplinary care is essential to provide comprehensive care to individuals.

RECENT FINDINGS

The challenges of implementing an effective multidisciplinary care team can be daunting. Effective multidisciplinary care begins at the initial diagnosis of heart failure. The transition of care from the inpatient to the outpatient setting is critically important. The use of home visits, case management, and multidisciplinary clinics has been shown to decrease mortality and heart failure hospitalizations, and major society guidelines endorse multidisciplinary care for heart failure patients. Expanding heart failure care beyond cardiology entails incorporating primary care, advanced practice providers, and other disciplines. Patient education and self-management are fundamental to multidisciplinary care, as is a holistic approach to effectively address comorbid conditions. Ongoing challenges include navigating social disparities within heart failure care and limiting the economic burden of the disease.

Using an individualized pain management plan for African American adults with sickle cell disease

BACKGROUND

The increased lifespan of individuals having sickle cell disease (SCD) causes an overall increase in hospitalizations and more instances in which pain may not be well controlled.

LOCAL PROBLEM

The mainstay treatment for severe pain is opioids and the underlying cause. Laws affecting opioid prescribing, implicit bias, racial inequity, poor research funding, and lack of knowledge contribute to poor patient outcomes.

METHOD

Data were collected retrospectively using electronic medical record data from before and after the intervention.

INTERVENTION

The individualized pain management plan (IPMP) was initiated in collaboration with the patient, pain nurse practitioner (NP), and hematologist.

RESULT

The mean length of stay for the traditional pain management plan (TPMP) was 7.89 days compared with 5.66 days for the IPMP, with a mean difference of 2.23 days, t = 2.278, p = .024 ( p < .05). There was a decrease in the admission of the individuals with the IPMP, with 25% readmitted within 30 days of discharge, versus 59.0% who were readmitted using the TPMP. Chi-square showed statistical significance (χ 2 = 61.667, p = .000) in using nonpharmacological interventions with the IPMP group.

CONCLUSION

The IPMP with a patient-centered approach did improve patient outcomes for African American adults living with SCD.

Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review

BACKGROUND

The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes.

OBJECTIVES

To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP.

METHODS

This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions.

RESULTS

A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses.

CONCLUSION

Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.