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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 198-205

A study to evaluate the feasibility of a nurse-led follow-up clinic among postmyocardial infarction patients attending the Cardiology Outpatient Department at CN Centre, AIIMS, New Delhi


1 Nursing Officer, IRCH, New Delhi, India
2 College of Nursing, AIIMS, New Delhi, India
3 Department of Cardiology, AIIMS, New Delhi, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. L Gopichandran
College of Nursing, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_52_18

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  Abstract 

Introduction: Nurse-led clinics are a model of care indicated where there are service gaps due to high demand or workforce shortages. Objective: The objective of this study was to evaluate the feasibility of a nurse-led follow-up clinic among postmyocardial infarction (MI) patients by inter-rater agreement of selected clinical variables with cardiologist clinic and to assess the satisfaction among post-MI patients related to assessment and recommendations done in a nurse-led follow-up clinic. Materials and Methods: Quasi-experimental evaluation design – only posttest using a comparison group was used. Convenience sampling was done. From three follow-up clinics, 79 participants were included, and the interventions were post-MI patients' assessment, documentation, and recommendations, which were done in both nurse-led and cardiologist follow-up clinics using post-MI clinical pro forma. Results: The overall inter-rater agreement ranges from 87.34% to 99.8%. The kappa score obtained was found to be highly significant (P = 0.0001). 86% of patients were highly satisfied and only 14% were moderately satisfied, and the total mean score was 34.47 ± 6.15. Conclusion: The nurse-led clinic was feasible among post-MI patients after proper training of nurse.

Keywords: Inter-rater agreement, nurse-led follow-up clinic, patient satisfaction, postmyocardial infarction follow-up, selected clinical variables


How to cite this article:
Usha P, Gopichandran L, Pathak P, Parakh N, Ramakrishnan S, Singh S. A study to evaluate the feasibility of a nurse-led follow-up clinic among postmyocardial infarction patients attending the Cardiology Outpatient Department at CN Centre, AIIMS, New Delhi. J Pract Cardiovasc Sci 2018;4:198-205

How to cite this URL:
Usha P, Gopichandran L, Pathak P, Parakh N, Ramakrishnan S, Singh S. A study to evaluate the feasibility of a nurse-led follow-up clinic among postmyocardial infarction patients attending the Cardiology Outpatient Department at CN Centre, AIIMS, New Delhi. J Pract Cardiovasc Sci [serial online] 2018 [cited 2019 Jan 19];4:198-205. Available from: http://www.j-pcs.org/text.asp?2018/4/3/198/249935


  Introduction Top


Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality globally. In the Indian subcontinent, more than 25% of deaths are due to CVD. Smoking, hypertension, diabetes, hyperlipidemia, and obesity are major risk factors and are modifiable. However, many patients presented with multiple risk factors. The other risk factors were age, premature family history of CVD, and physical inactivity.[1] Marked increase in both CVD prevalence and risk factors was observed in urban India as compared with rural settings.[2]

Coronary artery disease is common among CVD, of which myocardial infarction (MI) is a common presentation.MI is now considered as a part of acute coronary syndrome spectrum. Globally, more than 7 million people experience MI every year; 1-year mortality rate is around 10%, and nearly 20% of people suffer a second cardiovascular event within a year.[3] Post-MI complications were found more in Q-wave MI (62.2%) than non-Q-wave MI (30.8%). Patients with Q-wave MI presented with a higher incidence of complications such as hypotension, congestive cardiac failure, reinfarction, and left ventricular failure. Hence, they require long-term management and follow-up for an indefinite period. Thefirst 3 months is a crucial time for a reinfarction.[4]

A survey report of 2013 showed that accessibility and affordability for acute care management, long-term secondary prevention practices, and compliance are lacking in CVD patients and have attributed to a grim scenario for the evolving epidemic of coronary heart disease in India.[5] According to the Cardiological Society of India, the country has “<4000 cardiologists and 1200 cardiac surgeons for a population of 1.2 billion.”[6] Faced with a crippling shortage of health-care specialists, the Ministry of Health is planning to introduce nurse practitioners (NPs) in selected disciplines such as oncology, neurology, critical care, cardiovascular care, and anesthesia. Nurse-led clinics (NLCs) are not a common practice in India. However, it has been functioning in the US since the 1960s, the UK since 1980s, Australia since 1990s, and the Netherlands since 2012. NLCs are mainly run by nurses independently or supported by a multidisciplinary team with advanced skills and knowledge and can work autonomously. In these clinics, nurses make detailed physiological assessment, subsequent care planning, delivery of treatments, monitoring of the patient condition, management of medication, patient health education and refer to other colleagues when indicated.[7],[8],[9],[10],[11]

A randomised controlled trial revealed that there was no significant difference between the NLC and resident-led clinic regarding mortality (0%), reinfarctions (2%), or length of stay. However, the patients treated by the NP expressed a significantly higher score in satisfaction.[10]


  Materials and Methods Top


This was a quasi-experimental evaluation design – only posttest using a comparison group.

Study group

Selected patients who had MI intervened by a nurse in NLC.

Comparison group

The same patients of NLC intervened by a cardiologist in cardiologist follow-up clinic, and it also acts as a control by considering the Cardiologist fnding as a gold standard.

X-intervention

Post-MI patient's assessment, recommendations, and documentations.

O-posttest

The outcome of the study evaluated by inter-rater agreement between nurse-led and cardiologist follow-up clinic as well as patient satisfaction level related to Nurse led clinic [Table 1].
Table 1: Study design

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The study was conducted at CN Centre, Cardiology Outpatient Department (OPD), AIIMS, New Delhi. The sample size was 50 and was calculated based on the previous review by keeping 80% power (expected 80% of patient satisfaction) using the formula n = (2α + 2β)2 62 / (m1-m2)2. To add more power to the study, 79 patients were enrolled by convenient sampling method. The patients were selected from follow-up clinics of specific cardiology OPD at CN Centre, AIIMS, New Delhi, from June 2016 to January 2017 as per the following inclusion criteria: willingness to participate and able to read/understand Hindi or English, and clinical presentation of either STEMI or NSTEMI. Patients who underwent coronary artery bypass grafting, patients with chronic systemic illness like cancer, chronic kidney disease etc. were excluded from the study. The data collection process involves the following: (1) identification of typical or atypical clinical presentation, (2) identification of the New York Heart Association (NYHA) classification, (3) interpretation of post-MI electrocardiography (ECG) changes, (4) identification and recommendation of various investigation needs, (5) identification and recommendation of various drug modification need, and (6) recommendation of treatment plan. The above said were the independent clinical variables assessed and documented by using a semistructured post-MI clinical pro forma and it also includes history collection, focused cardiovascular assessment, ECG interpretation, checking of blood reports, and investigations. Cardiologist clinical findings were considered as gold standard for the study, and the study evaluation was done by inter-rater agreement range between nurse-led and cardiologist follow-up clinic. The rating was excellent (more than 90%), good (71%–90%), moderate (51%–70%), and poor (<50%). The expected inter-rater agreement was >75% in each selected clinical variable of patients. The patient satisfaction scale was another copyright tool. The tool, a Likert scale, has eight subdomain questionnaire statements and the response rated were 5 (strongly agree), 4 (agree), 3 (don't know), 2 (disagree), and 1 (strongly disagree). The scores were (31–40) highly satisfied, (21–30) moderately satisfied, (11–20) dissatisfied, and (≤10) highly dissatisfied. The content validity of the tools was done by two medical experts of cardiology department and three nursing experts of different specialties. The reliability of the tools was assessed using Cronbach's alpha. The reliability of post-MI clinical pro forma was 0.83 and 0.86 for patient satisfaction scale.

Ethical considerations

It was obtained from the ethical committee of AIIMS, New Delhi. Written informed consent was taken. Confidentiality of the information and anonymity of the patients were maintained.

Training provided for the nurse

The researcher was trained by a cardiologist, Department of Cardiology, AIIMS, New Delhi, regarding post-MI patients' assessment, recommendations, and documentations at a follow-up clinic of specific cardiology OPD for a period of 6–8 weeks. Posttraining, competency certificate was obtained by the researcher.

Intervention

It includes post-MI patients' assessment, documentation, and recommendations of findings. The assessment part has a history collection that included chief complaints, present history, past history, family history, personal history, interpretation of previous and present ECG changes, checking of blood reports for lipid profile, blood sugar, hemogram, liver function test and renal function test, and other investigations such as echo report, coronary angiography report, and stress thallium report. The researcher correlated the relevant findings with investigation reports as well as treatment undergone, following which focused cardiovascular assessment was done based on the present condition, and the present clinical presentation was identified. Based on the assessment findings, the need for drug modification, further investigation, or continuation of the same treatment was documented and recommended. The flow diagram of the intervention process is depicted in [Figure 1].
Figure 1: Intervention process flow diagram.

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Statistical design

Data analysis was done using Statistical Package for Social Sciences (SPSS) version 16 and its origin is SPSS Inc. in Chicago, its historical number is 17918. Both descriptive and inferential statistics were used. Descriptive statistics, such as frequency and percentage, were used to describe demographic and patient disease characteristics. Inferential statistics, such as kappa agreement, was used to assess the inter-rater agreement between the nurse- and cardiologist-led clinic. Sensitivity and specificity, test was done to assess the ability of nurse-led follow-up clinic to detect a patient's normal and abnormal findings or presentation. Pearson's Chi-square test was also used to evaluate the association between selected demographic variables with selected disease characteristic variables.


  Results Top


[Table 2] shows the frequency and percentage distribution of the demographic profile of patients with MI. The majority (81%) of the patients were male, and nearly half (40.5%) of the patients were under the age group of 51–60 years and 2.5% were young men (20–30 years).
Table 2: Patient demographic profile (n = 79)

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[Table 3] shows the frequency and percentage distribution of the patient disease profile. More than half (54.4%) of the patients had multiple risk factors of MI, with smoking (26.6%) as the single predominant risk factor of MI. The majority (93.7%) of them had thefirst attack of MI and nearly half (45.5%) of them had an anterior wall MI and 22.8% had NSTEMI. As far as the window period of MI, half (50.63%) of the patients had a window period of more than 12 h and only 37.97% had a window period of <6 h. Regarding the treatment done, two-fifth (40.5%) of the patients underwent conservative management and one-fifth (27.9%) underwent primary PTCA and only less than one-fifth(12.6%)of them had a thrombolytic history.
Table 3: Patient disease profile (n = 79)

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[Table 4] shows excellent agreement (94.94%) between nurse and cardiologist in the identification of patients' clinical presentation. The kappa score was 0.89 (0.80–0.99 with 95% confidence interval) and was highly significant (P = 0.0001*).
Table 4: Comparison of patients' clinical presentation identified by nurse and cardiologist in follow-up clinics (n = 79)

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[Table 5] shows excellent agreement (96.20%) between nurse and cardiologist in the identification of patient NYHA classification. The kappa score was 0.92 (0.75–0.97 with 95% confidence interval) and was highly significant (P = 0001).
Table 5: Comparison of patients' New York Heart Association classification identified by nurse and cardiologist in follow-up clinics (n = 79)

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[Table 6] shows excellent agreement (91.14%) between nurse and cardiologist in the interpretation of post-MI patients ECG changes. The kappa score was 0.81 (0.75–0.97 with 95% confidence interval) and was highly significant (P = 0.0001*).
Table 6: Comparison of patients' electrocardiography changes interpreted by nurse and cardiologist in follow-up clinics (n = 79)

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[Table 7] shows excellent agreement (99.8%) between nurse and cardiologist in various investigation recommendations for post-MI patient. The kappa score was 1.000 (0.84–0.99 with 95% confidence interval) and was highly significant (P = 0.0001).
Table 7: Comparison of various investigations recommended by nurse and cardiologist in follow-up clinics (n = 79)

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[Table 8] shows good agreement (87.34%) between nurse and cardiologist in various drug modification recommendations. The kappa score was 0.74 (0.53–0.96 with 95% confidence interval) and was highly significant (P = 0.0001).
Table 8: Comparison of various drug modifications recommendations by nurse and cardiologist in follow-up clinics (n = 79)

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[Table 9] shows excellent agreement (87.34%) between nurse and cardiologist in identifying a treatment plan for the patient. The kappa score was 0.82 (0.70 –0.95 with 95% confidence interval) and was highly significant (P = 0.0001).
Table 9: Comparison of Treatment plan recommended by nurse and cardiologist in follow-up clinics (n = 79)

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[Figure 2] illustrates the overall inter-rater agreement, ranging from 87.34% to 99.8%. Excellent agreement (>90%) was obtained between nurse and cardiologist in most of the selected clinical variables and good agreement (71%–90%) in various drug modification and treatment plan recommendations. The highest agreement (99.8%) was obtained toward various investigation recommendations.
Figure 2: Overall inter-rater agreement between nurse-led follow-up clinic and cardiologist follow-up clinic among selected clinical variables.

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[Figure 3] shows very absolute sensitivity and specificity (99.8%) in the identification of various investigations need, absolute sensitivity and specificity (≥90%) in the clinical presentation identification, and good sensitivity and specificity (≥80%) in the identification of drug modification needs.
Figure 3: Overall sensitivity and specificity of nurse-led follow-up clinic among postmyocardial infarction patient.

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[Figure 4] represents that most (86%) of the patients were highly satisfied with nurse-led follow-up clinic, and only 14% of patients were moderately satisfied. None of the patients were dissatisfied with nurse-led follow-up clinic. The mean satisfaction score was 34.47 ± 6.150 out of a total score of 40.
Figure 4: Nurse-led clinic – overall patient satisfaction score interms of percentage

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[Table 10] depicts that most of the patients agreed to all the statements related to nurse-led follow clinic, except for the statement whether they would like to attend nurse-led follow-up clinic even in the presence of a doctor.
Table 10: Nurse-led clinic patient satisfaction questionnaire subdomain scores regarding frequency and percentage

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  Discussion Top


The overall inter-rater agreement between nurse-led and cardiologist follow-up clinic ranges from 87.34% to 99.8%. The study results are similar with the study finding of Paul et al. (2014),[12] in which the overall inter-rater agreement between trained nurse and neurologist was 76%–94%. The variation in the inter-rater agreement may be due to differences in the study setting, differences in training of a nurse, or due to less categorization of variables in the present study.

Excellent agreement existed between nurse and cardiologist in most of the selected clinical variables, and a good agreement existed in various drug modification and treatment plan recommendations. The present study results are contrasted to the results of Paul et al. (2014),[12] where good agreement existed between trained nurse and neurologist in most of the selected clinical variables. However, in recognition of drug side effects, more than 90% agreement was found.

Good agreement (87.34%) existed in initiating treatment changes between nurse and cardiologist. The results were contradictory with the results of Leslie et al.,[13] which reported that nurses were better at documenting symptoms and addressing secondary prevention but were less confident in initiating treatment changes.

According to Paul et al. (2014),[12] nurse-led epilepsy clinic revealed good sensitivity and absolute specificity among all selected clinical variables. The study results are contradictory to the present study, which showed that nurse-led post-MI clinic obtained absolute sensitivity and specificity in all selected variables.

With regard to patient satisfaction related to NLC, Paul et al. (2014)[12] revealed that the total patient mean satisfaction score was 37.63 ± 3.36 with higher satisfaction in 96% of the participants and only 4% were moderately satisfied. The finding is similar to the findings of the current study, in which 86% of the participants were highly satisfied, with 14% of them being moderately satisfied, and the total patient mean satisfaction score was 34.47 ± 6.15.

Mostly, 86% of participants were highly satisfied, and only 14% were moderately satisfied related to NLC. The present study results are supported by that of Shakeel et al.,[14] where 80% of patients were very satisfied and 8% were satisfied with the overall care in the clinic. Furthermore, Broers et al.[15] concluded that the patients treated by the NP expressed a significantly higher score in the satisfaction domain.

Around three-fourth (73.5%) of the patients agreed that they would like to attend Nurse-led follow-up clinic in the future and 26.5% of the participants reported that they do not know whether they would attend nurse-led follow-up in the future. The finding is contradictory with the findings of Paul et al. (2014),[12] in which majority of the participants (84.5%) intended to attend NLC in the future.

According to patient satisfaction, nearly half (46.8%) of the patients were agreed that they would like to attend Nurse-led follow-up clinic even in the presence of doctor whereas 53.2% expressed they do not know about the decision. This study finding was contradictory with the study findings of Paul et al. (2014),[12] which reported that 92% of the participants intended to attend a nurse-led follow-up in the absence of a doctor. The reason could be the variance in patient expectation in a different setting and sample size.

Additional findings

The most common risk factor for males was multiple risk factors (56.2%) and the second most common was smoking (31.20%). Among females, the most common risk factor was multiple risk factors (46.7%), and the other common were diabetes (26.7%) and hypertension (13.3%). The findings are depicted in [Figure 5].
Figure 5: Association of risk factors of myocardial infarction with sex of the patient.

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As age increased, the total mean satisfaction score of patients also increased in the age group of 20–50 years.

Almost 38% of the participants needed advice regarding medication noncompliance and around 26.6% needed smoking cessation advice.

Strength of the study

The present study is thefirst experimental nurse-led post-MI follow-up clinical trial in India. Adequate training by the researcher was obtained. The study findings showed higher patient satisfaction.

Study limitations and recommendations

The study was done in a selected OPD clinic with a smaller sample size and lack of randomization, and blinded approach was not done.

Recommendations include a larger sample size with a blind approach. Other health personnel, especially doctor's satisfaction, can be included along with patient satisfaction. Studies with different methodology could be done.


  Conclusion Top


The present study suggests that the NLC is feasible among post-MI patients after proper training of the nurse. The majority of the patients were highly satisfied, and they would like to attend a nurse-led follow-up clinic even in the presence of a doctor.

Acknowledgment

P. Usha would like to thank especially the guides Dr. L. Gopichandran, Lecturer, CON, AIIMS, and Dr. Neeraj parakh, Associate professor, Cardiology, AIIMS, for their full support and all cardio-senior residents for their cooperation during the training and data collection period. A heartfelt gratitude to Mrs. Preeti Paul for the copyright permission of the tool and special thanks to my family and friends, especially Ms. Lilly Monika for the help and support for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Coronary Artery Disease Definition – Google. Available from: https://www.google.co.in/search. [Last accessed on 2016 Aug 20].  Back to cited text no. 1
    
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Nagamalesh UM, Abhinay T, Naidu KC, Ambujam N, Hegde AV, Prakash VS. Clinical profile of young Indian women presenting with acute coronary syndrome. J Clin Prev Cardiol [Internet] 2018;7:106-10. Available from: http://www.jcponline.org/text. [Last cited on 2018 Dec 05].  Back to cited text no. 5
    
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2-Year Course to Upgrade Nurses to Care Staff. The Indian Express; 2015. Available from: http://www.indianexpress.com/article/india. [Last accessed on 2016 Dec 23].  Back to cited text no. 7
    
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Hatchett R. Key issues in setting up and running a nurse-led cardiology clinic. Nurs Stand 2005;20:49-53.  Back to cited text no. 9
    
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Paul P, Agarwal M, Bhatia R, Vishnubhatla S, Singh MB. Nurse-led epilepsy follow-up clinic in India: Is it feasible and acceptable to patients? A pilot study. Seizure 2014;23:74-6.  Back to cited text no. 12
    
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Leslie SJ, Katikreddi V, Geddes J, Perkins S, Hargreaves AD. Nurse-led versus physician-led post-myocardial infarction review clinics: A retrospective study. Br J Card Nurs 2006;1:341-6.  Back to cited text no. 13
    
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Broers CJ, Smulders J, van der Ploeg TJ, Arnold AE, Umans VA. Nurse practitioner equally as good as a resident in the treatment of stable patients after recent myocardial infarction, but with more patient satisfaction. Ned Tijdschr Geneeskd 2006;150:2544-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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