|Year : 2020 | Volume
| Issue : 1 | Page : 53-60
Effectiveness of a structured heart failure clinical pathway on nurses' knowledge and patient care outcomes
Jerlin Joseph1, L Gopichandran1, Sandeep Seth2, Milan Tirwa1
1 College of Nursing, AIIMS, New Delhi, India
2 Department of Cardiology, AIIMS, New Delhi, India
|Date of Submission||23-Dec-2019|
|Date of Decision||17-Mar-2020|
|Date of Acceptance||27-Mar-2020|
|Date of Web Publication||17-Apr-2020|
Associate Professor, College of Nursing, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Background: The global burden of heart failure (HF) is affecting at least 26 million people worldwide, and its incidence and prevalence are increasing. Management of patients suffering from HF requires a multidisciplinary management tool which is based on evidence-based practices. A clinical pathway (CP) has emerged as an essential strategy for knowledge transition, which helps in promoting effective health care in all disciplines of health care. The Objectives of the Study: The objectives of the study are to assess the effectiveness of a structured HF CP on nurses' knowledge and patient care outcomes in the Cardiology Department, AIIMS, New Delhi. Materials and Methods: This quasi-experimental study was conducted among 71 nurses working in the cardiac care unit (CCU) and cardiology (CT3) ward and 60 admitted acute decompensated HF patients. The study had three phases: preimplementation phase, implementation phase, and postimplementation phase. The implementation of the structured HF CP was made through an education session for nurses. Results: The nurses' knowledge and the patients' outcomes were assessed and compared before and after implementation of the CP. The knowledge score of the nurses had improved statistically significantly from 11.38 ± 2.9 to 16.85 ± 2.4 (P < 0.0001), after the implementation of the structured HF CP. With regard to patient outcomes, the postimplementation group had significant improvement when compared with the preimplementation group in terms of administration of beta-blockers (P = 0.028) and vaccination (P = 0.037). There was a clinically significant reduction in the length of intensive care unit stay, length of hospital stays, in-hospital mortality, and 30-day readmission and mortality in the postimplementation group than that in the preimplementation group.Conclusion: The implementation of the structured HF CP has improved the knowledge of the nurses working in CCU and CT3 ward and has also enhanced the outcomes of patients admitted in the Cardiology Department, AIIMS, New Delhi.
Keywords: Acute decompensated heart failure patient, nurses, patient care outcomes, structured heart failure clinical pathway
|How to cite this article:|
Joseph J, Gopichandran L, Seth S, Tirwa M. Effectiveness of a structured heart failure clinical pathway on nurses' knowledge and patient care outcomes. J Pract Cardiovasc Sci 2020;6:53-60
|How to cite this URL:|
Joseph J, Gopichandran L, Seth S, Tirwa M. Effectiveness of a structured heart failure clinical pathway on nurses' knowledge and patient care outcomes. J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Jul 10];6:53-60. Available from: http://www.j-pcs.org/text.asp?2020/6/1/53/282818
| Introduction|| |
The cardiovascular disease (CVD) burden in India is increasing. Globally, CVDs are the number one cause of death, and more people die annually from CVDs than from any other cause. Heart failure (HF) as the “end stage” of CVD requires chronic illness care as the prevalence of the disease is rising. The global burden of HF is affecting at least 26 million people worldwide, and its incidence and prevalence are increasing. In India, the estimated range of HF is between 1.3 and 4.6 million, with a prevalence of 0.12%–0.44%, and coronary artery disease is the leading cause of HF.
Acute decompensated HF (ADHF) represents one of the leading causes of hospital admissions of the elderly population despite the advanced treatment both in the medical and device therapy field. ADHF is defined as the acute onset or gradual progression of HF, which necessitates immediate medical attention and hospitalization. More than 80% of patients with ADHF present to the emergency department, and only selected patients are eligible to receive care for ADHF in a cardiac observation unit. Management of patients suffering from ADHF requires a balance between hemodynamic stability, improving symptoms and signs, and measures to reduce morbidity and mortality.
Multidisciplinary care management by a team approach for ADHF patients is considered the gold standard model for the delivery of care in both inpatient and outpatient settings to reduce the risk of HF hospitalization., A clinical pathway (CP) is a multidisciplinary management tool which is based on the evidence-based practices for the provision of quality health care concerning the standardization of care processes. The implementation of pathways reduces the variability in clinical practices and in-hospital complications, fosters communication among different disciplines, enhances documentation, and improves the outcome.
The key to the success of multidisciplinary HF programs led by cardiologists supported by physicians and specialized trained nurses may be the coordination of care along the spectrum of the severity of HF. This can be done through the standardization of a chain of care for patients in their journey from emergency admission to discharge and to then follow-up by the various services.,,,
Nurses play a vital role in caring for HF patients. Specialized care provided by HF nurses in outpatient settings with a structured follow-up focused on the optimization of therapy and education for self-care has reported a reduction in the risk of hospital readmission. Nurses in inpatient setup providing clinical nursing care to a patient suffering from heart disease require the application of knowledge of the disease process.
A comprehensive education intervention with continued reinforcement may prove useful in increasing the knowledge of acute HF management principles, among experienced acute care nurses. Nursing education is an essential factor that needs to be addressed before the implementation of CP. The implementation of the CP through the education program for nurses when performed in an interactive environment offers nurses a chance to learn and utilize the scenarios before its initiation into clinical practice. The key to the success of CPs is through nursing engagement and its implementation.
In view of the identified gaps and reviewing the previous studies on ADHF in the in-hospital setting, this study intended to use a HF CP for caring ADHF patients who are hospitalized to coordinate the management of care within various HF services and find the effectiveness of HF CP on nurses' knowledge and patient outcomes.
| Materials and Methods|| |
The sample size was calculated considering the mean ± standard deviation (SD) of the length of intensive care unit (ICU) stay in pre-CP implementation (2.99 ± 0.93) and post-CP implementation (0.17 ± 0.38). Presuming similar results for ADHF patients, with 90% power and 5% level of significance, the required sample size was found to be five in each arm. However, considering subgroup analysis, it was planned to take thirty patients in each arm for the study and by taking thirty patients, the variability that is likely to occur from baseline to postimplementation will be minimized. Sixty patients (thirty in each group) were conveniently enrolled in the study from the cardiac care unit (CCU) of a tertiary hospital in New Delhi. Total enumeration was done for nurses working in the CCU and cardiology ward of the hospital.
Patients who were admitted in the CCU within 24 h of admission in the hospital of age 18 years and above, who can understand Hindi/English, and who are in New York Heart Association (NYHA) III and NYHA IV classification were enrolled. Nursing Officers (Grade II) who were involved in direct ADHF patient care, working in cardiology department were included in the study. The schematic representation of the study is developed in the consort diagram and presented in [Figure 1].
HF CP refers to a structured care pathway that is developed by a multidisciplinary team including doctors and nurses and will be used to care for ADHF patients in terms of assessment, investigation, treatment, activity, diet, health education, and follow-up.
Knowledge is defined as the facts and information acquired by nurses through education and experience as assessed by a knowledge questionnaire that had questions from the five domains of ADHF patient assessment, management, associated complications, health education, and follow-up.
Patient care outcomes were measured by the HF patient care outcome checklist in terms of medication profile, vaccination, in-hospital mortality, NYHA classification, length of ICU, and hospital stay of ADHF patients in the cardiology department and readmissions and mortality within 30 days of discharge.
The sociodemographic and clinical profile of patients was collected using the structured self-developed data sheets, and a nurse data sheet was developed to collect data regarding their sociodemographics.
The study was carried out in three phases.
Nurses working in the selected setting and the patients who meet the inclusion criteria were enrolled in the study depending on their willingness to participate. Sociodemographic data and knowledge of the nurses on HF management were assessed. Sociodemographic data and the clinical profile of the patients and their outcomes were evaluated at discharge and 30 days following discharge through telephonic follow-up, using the HF patient care outcome checklist.
The structured HF CP [Figure 2] was implemented through a structured teaching program by the researcher for 25–30 min in small groups of 3–5 during the day duty hours among nurses to improve patient care outcomes.
|Figure 2: Structured heart failure (acute decompensated heart failure) clinical pathway.|
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The knowledge of the nurses was reassessed after 7 days of the educational session using the knowledge questionnaire, and the patients who were admitted to the hospital were enrolled 2 weeks after the implementation of the HF CP. Patient outcomes were assessed at discharge and 30 days following discharge through telephonic follow-up, using the HF patient care outcome checklist [Figure 3].
Preimplementation and postimplementation groups were telephonically followed up after 30 days of discharge.
The analysis was performed using SPSS software version 16, IBM. Descriptive statistics (mean, SD, percentage, and frequency) were used to describe the demographic and clinical characteristics. Inferential statistics included Chi-square test, Fisher's exact test, independent t-test, and paired t-test. The level of statistical significance was considered as P < 0.05.
| Results|| |
A total of 72 ADHF patients were screened, of whom 12 did not meet the inclusion criteria. Eight patients, five in preimplementation and three in the postimplementation group, expired during the hospital stay. Seven participants were lost to telephonic follow-up, three and four in pre- and post-implementation groups, respectively. The mean age of the patients in the preimplementation group was 53.06 ± 16.5 years and that of the postimplementation group was 55.3 ± 13.19 years. The majority of patients in both groups were male, and the groups were comparable in terms of demographic characteristics, NYHA classification, and clinical profile [Table 1].
|Table 1: Description of sociodemographic characteristics and clinical profile of acute decompensated heart failure patients before and after the implementation of the clinical pathway (n=60)|
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The mean age of the 71 enrolled nurses was 29.65 ± 3.2 years. The majority of nurses (64.8%) were female and hold BSc. Nursing professional qualification. The majority of nurses had cared for ADHF patients before the implementation of the CP, and most of them had not attended any education session on HF and its management within the last 6 months' duration of their knowledge assessment [Table 2].
|Table 2: Description of sociodemographic characteristics of nurses (n=71)|
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Outcomes of the structured heart failure clinical pathway
Comparison of knowledge score of nurses before and after implementation of the clinical pathway
All the mean ± SD scores in the domains of knowledge questionnaire of the nurses improved statistically significantly (P < 0.0001) from preimplementation to postimplementation of the structured HF CP with the education session [Table 3]. It was further seen that there was a difference in the percentage of nurses in each knowledge score category as poor (1–7), average (8–14), and good (15–20) before and after the implementation of the CP. Before the implementation of the CP, 80% of the nurses had an average score, 13% of the nurses had a good knowledge score, and about 7% of the nurses were in poor knowledge category [Figure 4]. After the implementation of the CP through education sessions, it was noticed that 79% of the nurses had a good knowledge score, whereas 21% of the nurses were in the average score category [Figure 5].
|Table 3: Comparison of domain.wise knowledge score of nurses before and after the implementation of the clinical pathway (n=71)|
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|Figure 4: Pie char t showing the percentage of nurses in each knowledge score category before the implementation of the clinical pathway.|
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|Figure 5: Pie char t showing the percentage of nurses in each knowledge score category after implementation of the clinical pathway.|
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Comparison of patient care outcomes before and after implementation of the clinical pathway
All the patients in both the preimplementation and postimplementation groups received injectable diuretics at the time of admission. Beta-blockers or ivabradine were administered to only 53.3% of the patients in the preimplementation group, whereas 80% of the patients in the postimplementation group received the drug before discharge from the hospital, and this difference was statistically significant at P = 0.028. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers or angiotensin II receptor blocker neprilysin inhibitor or hydralazine or other nitrates and mineralocorticoid receptor antagonist administration increased from preimplementation to postimplementation group at P = 0.082 and P = 0.058, respectively.
The number of ADHF patients vaccinated with pneumococcal and influenza statistically significantly increased in the postimplementation group (P = 0.037). There was a clinically significant reduction in the length of ICU stay, length of hospital stays, and in-hospital mortality in the postimplementation group than that in the preimplementation group. The telephonic follow-up done after 30 days of discharge found a decreased number of readmission and death in the postimplementation group, although it was not statistically significant [Table 4].
|Table 4: Comparison of patient outcomes before and after implementation of the heart failure clinical pathway (n=60)|
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| Discussion|| |
Management of ADHF patients in a hospital setting is an important aspect that needs to be addressed to reduce the mortality and morbidity of HF patients. Implementation of a CP for early assessment and management of ADHF patients through an educational session for nurses proved to be an appropriate strategy that can be taken forward for the management of these patients with sound knowledge.
Nurses' knowledge score before and after the implementation of the clinical pathway
The present study demonstrated that nursing officers' knowledge had improved statistically significantly from 11.38 ± 2.9 to 16.85 ± 2.4 (P < 0.0001), after the implementation of the structured HF CP. The findings of this study are congruent with those of other studies,, which revealed that the mean scores of nurses' knowledge showed a significant difference between pre- and post-CP education regarding the CP at P < 0.05.
Other studies, also found that an educational intervention on HF principles improved nurses' knowledge of the heart.
Patient care outcomes before and after the implementation of the clinical pathway
Results from the Carvedilol or Metoprolol European Trial and OPTIMIZE-HF studies demonstrated that the risk of death was higher in patients with ADHF whose beta-blocker dose was reduced or discontinued altogether; the initiation of a low dose of a beta-blocker is recommended only after the patient is hemodynamically stable and injectable diuretics, vasodilators, and inotropes are discontinued, and continuing the administration of beta-blocker and ACEI therapies during ADHF has been shown to be beneficial.,, The present study demonstrated that the implementation of the CP could significantly improve the administration of beta-blockers in ADHF patients at P = 0.028.
Respiratory infection is a major driver of morbidity in patients with HF, and many influenza and pneumococcal infections can be prevented by vaccination. According to the findings of the present study, vaccination with pneumococcal and influenza vaccines for patients hospitalized with ADHF has significantly increased in the postimplementation group that is 36.67% from 13.33% in the preimplementation group at P = 0.037.
A study done on hospitalized HF patients found that nearly one in three patients were not vaccinated for influenza or pneumococcal pneumonia, and this finding is similar to the present study. Findings from a study are in agreement with the current study which showed decreases in 30-day mortality rate in postimplementation group patients, in which 36.67% of them had received the vaccination.
The mean days of the length of ICU stay and hospital stay was reduced to 8.8 ± 2.12 and 15.83 ± 3.2 in the postimplementation group from 9.76 ± 3.58 and 16.56 ± 5.11 in the preimplementation group in the present study. Findings of a study on the implementation of the CP are in agreement with the current study which showed a clinically significant reduction in mean days of the length of ICU stay and hospital stay. Another study on multidisciplinary team management through care pathway found that shorter duration of hospital stay was achieved in congestive HF patients.
The present study showed a clinically significant difference between the preimplementation group and the postimplementation group in terms of 30 days of readmission and mortality. These findings are incongruent with those of a study which showed that there was an insignificant decrease in complication and hospital readmission. Other studies on HF patient outcome, found that readmission/death occurred in 26% of patients within 30 days of discharge, and the findings are in agreement with those of the present study which showed a 27.3% readmission rate and 10% mortality rate within 30 days of discharge.
The strength of this study lies in the fact that it was the first experimental study to assess the effectiveness of structured HF CPs in India for the management of ADHF patients during hospitalization. Some of the limitations of the study were small sample size, short follow-up time, and single-center study design, which prevented the randomization of patients and thus limited the generalizability of the study. The findings of the present study yield information regarding the importance of strengthening the nurses' knowledge to care for ADHF patients and the need to coordinate the various services through a multidisciplinary approach to improving patient care outcomes. Furthermore, emphasis should be laid upon the nursing curriculum on the concept of incorporating the importance of structured clinical care pathway in the HF management strategy to ensure continuity of care.
| Conclusion|| |
The implementation of a HF CP had improved the knowledge of nurses related to the management of ADHF patients. It can be concluded that CP implementation through an educational session for nurses has a positive impact on the nurses' knowledge and improves patient outcomes. Furthermore, this study projects the importance of clinical care pathways which act as the outline of the sequence and timing of actions necessary for achieving expected patient outcomes.
Ethical clearance was obtained from institutional ethical committee, AIIMS, New Delhi.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gardetto NJ. Self-management in heart failure: Where have we been and where should we go? J Multidiscip Healthc 2011;4:39-51.
Holst DP, Kaye D, Richardson M, Krum H, Prior D, Aggarwal A, et al
. Improved outcomes from a comprehensive management system for heart failure. Eur J Heart Fail 2001;3:619-25.
Allen LA, O'Connor CM. Management of acute decompensated heart failure. CMAJ Can Med Assoc J 2007;176:797-805.
Fermann GJ, Collins SP. Observation units in the management of acute heart failure syndromes. Curr Heart Fail Rep 2010;7:125-33.
Fermann GJ, Collins SP. Initial management of patients with acute heart failure. Heart Fail Clin 2013;9:291-vi.
Morton G, Masters J, Cowburn PJ. Multidisciplinary team approach to heart failure management. Heart 2018;104:1376-82.
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22611136
. [Last accessed on 2019 Jan 03].
Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med 2010;8:31.
Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, et al
. Clinical pathways: Effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010;3:CD006632.
Frankenstein L, Fröhlich H, Cleland JG, Frankenstein L, Fröhlich H, Cleland JG. Multidisciplinary approach for patients hospitalized with heart failure. Rev Esp Cardiol 2015;68:885-91.
Riley J. The key roles for the nurse in acute heart failure management. Card Fail Rev 2015;1:123-7.
Al-Qalah TA, Mukhtar HF. Effectiveness of a Clinical Pathway Education Program for Cardiac Nurses; 2017:4;56-61.
Rajeswari U, LathaVenkatesan UR, Sonia AL. Effectiveness of clinical pathway for parturient mothers upon knowledge and practice of nurses and maternal outcome. Asian J Nurs Educ Res 2012;2:90-5.
Sundel S, Ea EE. An educational intervention to evaluate nurses' knowledge of heart failure. J Contin Educ Nurs 2018;49:315-21.
Mahramus T, Penoyer DA, Frewin S, Chamberlain L, Wilson D, Sole ML. Assessment of an educational intervention on nurses' knowledge and retention of heart failure self-care principles and the Teach Back method. Heart Lung J Acute Crit Care 2014;43:204-12.
Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, et al
. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): Randomised controlled trial. Lancet Lond Engl 2003;362:7-13.
Abraham WT, Fonarow GC, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al
. Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). J Am Coll Cardiol 2008;52:347-56.
Butler J, Young JB, Abraham WT, Bourge RC, Adams KF, Clare R, et al
. Beta-blocker use and outcomes among hospitalized heart failure patients. J Am Coll Cardiol 2006;47:2462-9.
Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, et al
. Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET. Eur J Heart Fail 2007;9:901-9.
Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al
. Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: Findings from the OPTIMIZE-HF program. J Am Coll Cardiol 2008;52:190-9.
Bhatt AS, Liang L, DeVore AD, Fonarow GC, Solomon SD, Vardeny O, et al
. Vaccination trends in patients with heart failure: Insights from get with the guidelines–heart failure. JACC Heart Fail 2018;6:844-55.
Modin D, Jørgensen ME, Gislason G, Jensen JS, Køber L, Claggett B, et al
. Influenza Vaccine in Heart Failure: Cumulative number of vaccinations, frequency, timing, and survival: A Danish Nationwide Cohort Study. Circulation 2019;139:575-86.
Cheah J. Clinical pathways – An evaluation of its impact on the quality of care in an acute care general hospital in Singapore. Singapore Med J 2000;41:335-46.
Lanzieri M, Hobbs R, Roy P, Richmond R. Use of a clinical care map for the management of congestive heart failure in a community hospital. Congest Heart Fail 2001;7:37-42.
Vader JM, LaRue SJ, Stevens SR, Mentz RJ, DeVore AD, Lala A, et al
. Timing and causes of readmission after acute heart failure hospitalization – Insights from the heart failure network trials. J Card Fail 2016;22:875-83.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]