Evidence-based Management of Congestive Heart Failure

Evidence-based Management of Congestive Heart Failure
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Abstract
Despite major advances over the years in the treatment of heart diseases, people aged above 65 years are at risk of being diagnosed with Congestive Heart Failure (CHF). The illness is considered dangerous, even in its mildest form. Although most people who visit medical centers receive treatment, there is still a high rate of readmission. The problem is fostered by the lack of adherence among the patients in medication. The severity of the illness requires that patients are offered recurrent education and care services including how they should take medicine, eating habits, exercises, and going for checkups. The lack of these services increases the chances of a patient being readmitted. The solution to these issues requires an approach that supports the provision of care in the home setting. Home-based health care provision can be implemented through a multidisciplinary approach. A credible body of research shows that this approach has been effective in improving the healthcare system. It facilitates the engagement of various people in providing care. In this context, a multidisciplinary approach can be used for CHF patients by engaging professionals in the health care, social work, and family members. A challenge in using this approach is the financial burden incurred in health care services. Evidence-based initiatives such as multidisciplinary require a strategic approach to implementation and sustainability through appropriate budgeting and leadership.

Evidence-based Management of Congestive Heart Failure
Introduction
The management of heart failure is increasingly becoming a challenge for caregivers across the globe. Particularly, the increasing aging population has led to a rise in the occurrence of heart diseases, which adds to the financial burden of the patients, families, and the government. It is imperative that professionals in the healthcare industry come up with amicable solutions to treating and preventing heart diseases. One of the lethal conditions is the Congestive Heart Failure (CHF). It is highly prevalent among people aged 65 and above. According to Vinson et al. (1990), the illness is common among people who have a background of recurrent heart failure. According to McKee, Castelli, McNamara, Kannel, & McKee PA, Castelli WP, McNamara PM(1971), the condition is highly experienced in the developed world with 1-2% of the population aged 70 and above being diagnosed with the disease (McAlister, Stewart, Ferrua, and McMurray, 2004). Further reviews by Neubauer (2007) points out that 30-40% of CHF patients die within one year of receiving treatment for the disease. CHF is an illness that develops progressively over time and severe damage to the heart can occur before the individual is aware. It is evident that even in mild forms, CHF is risky and challenging to manage. CHF is deemed to be an ever gradually changing illness, particularly for people who lack adequate information on the challenges caused by the disease. The intent of this paper is to propose an evidence-based approach to managing CHF.
Problem
Evidence from various reviews shows that the management of CHF can be challenging to some extent due to the patient's inability to comply with the given directions. Suggestively, the main problem facing the treatment of CHF is the high tendency among patients not to comply with prescriptions as well as minimal evidence-based means of advocacy among these individuals to promote adherence to recommended medication. In this light, Li, Morrow-Howell, and Proctor (2004) allude that patients have a role to play for treatment procedures to be successful. The authors allude that patients must not assume a passive role in their plan of care if an exacerbation and an improvement of the quality of life are to be guaranteed. Failure to engage appropriately in the medication leads to most of the congestive heart failure patients that are discharged from hospitals, ending up being readmitted in a worse state (Li et al., 2004). From this context, the health system lacks a strategic approach to treatment, despite the knowledge that most patients lack the efficiency to uphold the treatment program on by themselves.
Purpose
The aim of this project is to identify the best evidence-based programs that can be implemented to enhance the health care system in ensuring that CHF patients that have left the hospital do not degenerate and support self-care for such patients within a period of five months. Defining the best evidence-based program will aid in ensuring that there is an established framework for the selection and implementation of interventions that are utilized in treating heart failure among home care patients. Additionally, it will be instrumental to medical practitioners in offering expert, personalized care and enhancing the clients’ quality of life. The research will show how a multidisciplinary approach can be used to solve these challenges. According to Hines, Yu, and Randall (2010), there is a need of setting up a disease management (DM) program that is multidisciplinary in nature for individuals that are at greater risk of hospitalization or a worsening of their health condition. It is crucial that the team operates as a unit in dealing with the signs and other situations that might crop up. The use of a DM program has been found to reduce the readmission rates for high-risk CHF patients for up to 56% and a reduction of the cost for up to $460 per patient.
Study Question
The project will be guided by a PICOT question as follows:
In home care, patients above the age of 65 years that have congestive heart failure, will the introduction of nursing monitoring learning versus routine home care on its own lead to higher self-care and avert progression within five months after the discharge from an inpatient health care facility?
Literature Review
Congestive Heart Failure (CHF) is an acute illness, even in its mildest form suggesting that patients that suffer from the disease need constant monitoring and education on what to eat, exercise and medicines to take. Fundamentally, it is common among older people aged 65 and above who are less likely to be leading an active life. The most common etiologic precursors for CHF are coronary heart disease, hypertension, genetic inheritance, abuse of alcohol and viral infection among other causes (McMurray, 2010). A study done by McKee et al. (1971) for 16 years involving 5192 patients where 142 developed CHF, revealed that hypertension contributed to 75% of the etiologic precursors. Hypertension also accompanied coronary heart disease and percussive rheumatic heart disease. The study showed that the susceptibility to succumb to the disease within the first five years was 62% for men and 42% for women. Neubauer (2007) also suggests a model where the heart muscles or myofibrils are failing to produce enough energy needed to pump the heart. This is due to the fact that the heart requires a lot of energy every day to pump more than 10,000 liters of blood around the body. In the 10,000 times it beats during the day, it uses approximately 10Kg of Adenosine Triphosphate (ATP). The complex nature of CHF makes management difficult since the disease has a chronic habit.
Many reported cases of CHF usually undergo treatment, but readmission after discharge remains high. Li, Nancy, and Proctor (2004) observed this scenario where an annual mortality rate of CHF patients stood at 10% despite medical intervention to the problem. Similarly, Proctor, Morrow-Howell, Li, and Dore (2000) highlight the worrying trend of readmission among CHF patients. Many of the patients who undergo medical treatment and nursing care find themselves back in the hospital despite previously receiving treatment. A study by Hopp, Thornton, and Martin (2010) revealed that most CHF patients face significant challenges after discharge from hospitals. What contributes to their prevalence to readmission are social isolation, life disruption, and ambiguity about symptoms and prognosis. The lack of proper knowledge about the disease management, social support, and handling the dying process makes many of them susceptible to readmission in acute conditions (Stewart & Horowitz, 2002). Additionally, a lack of adherence to prescribed medication and diet also contributes to this, accounting for almost 29-47% of readmission after three to six months after original discharge (M. Rich et al., 1995).
Factors Affecting Prescription Compliance
Many medical practitioners have struggled to understand and solve the puzzle of recurrent CHF. Despite patients undergoing extensive pharmacotherapy, the prognosis of CHF continued to be impoverished (McAlister et al., 2004). Patients once discharged with reduced CHF conditions will return several months later in worse or very severe conditions; some finally succumbing to the ailment. The need to reduce unplanned readmissions and prolong survival of CHF patients is evident through their ineffective compliance to prescribed treatment caused by financial, psychosocial, and behavioral factors (Rich, 1999). The failure of medical practitioners to factor in the possibility of recurrence of the disease, aided in enabling negligence and ignorance among patients.
Additionally, Stewart, Pearson and Horowitz (1998) synopsis of this study shows that patients fail to comply with medical prescriptions despite counseling and knowledge of their health conditions because they incline to irresponsibility due to inadequate monitoring. The cases are more common among older people when one puts into perspective their need for assistance. A lack of a nurse visitation or a call to check the patient’s condition after discharge allowed for deterioration in the patient’s health, due to the lacking of authoritative monitoring.
A study by Proctor, Nancy, and Kaplan (1996) revealed that 40% of discharged patients failed to implement at least one discharge plan, with high discrepancies realized among low-income patients. The implementation discrepancies contributed to negative results through inadequate care, a little help and greater unmet needs (Proctor et al., 1996). Therefore, the high cost associated with caring for CHF patients is due to frequent readmissions to hospital for exacerbation. According to Jerant et al. (2001), this accounts for 16-25% of total readmissions.
Multidisciplinary Approach as an Alternative
The escalating cost of medical services and rising numbers of deaths due to CHF exacerbations necessitate for a medical and nursing care intervention beyond the hospital walls. Several studies have proven the profitability of home care interventions. A study conducted by Proctor et al. (2000), provided home care to 253 elderly patients and interviewed them in 2, 6, 10 and 14 weeks showed a high reduction in readmission cases. Another study by Stewart and Horowitz in 2002 showed an increase of 817 months of survival, fewer readmissions, and lower clinical visits costs for home-based intervention patients as compared to patients in the usual care. The significance of home-based initiative towards cost reduction and low mortality rate as well as lower readmission provides a means of improving the wellbeing of the CHF patients. Previously, there has been the application of several efforts to decrease readmission rates through the involvement of nurses and other medical practitioners in a patient’s recovery. Using home nurses to detect and manage CHF was found to reach timely decompensation, enhance family support, offer education about the disease and its treatment, which led to a reduction of readmission by 56% and expenses were cut by $460 per patient. Nevertheless, using these interventions was found to be costly and raised various challenges to the health care system (Jerant et al., 2001). Therefore, to reduce the number of visits, while at the same time monitoring patients effectively, it is imperative to utilize a multidisciplinary approach.
Jerant et al. (2001) show that using technology such as home Telecare (video conferencing), nurse’s telephone and the normal outpatient care reduced the cost of home visits by 85% compared with patients that needed visitation. Therefore, the multidisciplinary approach is cost effective both in improving a patient’s wellbeing and nurse’s logistics. Also, having the nurses perform home visits and medical practitioner offering cardiology and pharmacy consultations, the multidisciplinary approach seeks to involve family members and other non-medical stakeholders in the implementation of the HBI. HBI aids in the reduction of hospitalization and improvement in morbidity rates “among the elderly patient with severe form of CHF” (Kornowski, Zeeli, Averbuch, Finkelstein, Schwartz, Moshkovitz, &Levo, 1995). The aim of HBI is to promote the quality of life among the patients having CHF and provide assistance for their full recovery. This is important for the hospital and the individual.
The multidisciplinary approach shall require a close participation with the community. This shall oversee the incorporation of the social workers into the system. Social workers render their services towards the complete wellbeing of individuals in the community and shall work together with the medical team. The use of social workers in HBI shall aid in knowing the patients’ preferences and the best ways of approaching the nursing care (Morrison, Chichin, Carter, Burack, Lantz, & Meier, 2005). This shall be beneficial to the HBI since the patients and their families will have the opportunity to get education concerning the best practices to use during disease management and to sensitize the community to offer emotional and physical support to the patients towards full recovery.
According to Rich et al. (1993), the multidisciplinary intervention shall involve cardiologists, cardiac nurses, dieticians, physicians, and ambulance driver. The multidisciplinary approach shall expose the nurses and other members of the follow-up team for the challenges of working in multicultural settings. Therefore, nurses shall use therapeutically care plans to communicate with their patients and address their needs in a culturally sensitive manner. Cultural nursing care shall be in use as per the need. The social workers involved in the follow-up team shall aid in mitigating the challenge of cultural differences and language barriers since they come from the surrounding communities and works with them.
Proposed Solution
The proposed solution is to follow a disease management (DM) program that is multidisciplinary in nature. It is essential for individuals that are at a significant risk of worsening their health condition given that this kind of disease needs constant monitoring and guidance on what to eat, proper exercise, continuous treatment and factors that need to be avoided in order for hospital readmission to be prevented. A multidisciplinary approach program will be followed by the reduction of risk for patients to be hospitalized again. The disease management (DM) program of Hines and Randall (2010) will be followed. These include the strategic transition to the home setting for a patient, which will be assessed first. Care can be offered by family and outpatient caretakers and should be engaged in conducting assessments, establishing the needs of the outpatients, and the approach of discharging (Hines and Randall, 2010). Improved teaching and learning for the family and caregivers which include written, verbal and visual methods to understand the care requirements fully. There is also a great need for the guarantee of communication between the patient and their family to the caregiver to understand the patient’s needs and care plan. Lastly, a multidisciplinary initiative aimed at providing services to outpatients and their family members can be instrumental in reducing mortality, expenses, and involvement of people that include different individuals with specializations on this kind of disease, such as nurses, cardiologists and a primary care provider (Hines and Randall, 2010). The proposed approach is essential to decreasing the risk of readmission and further complication of the patient’s current condition considering its gravity and delicateness.
Requirements for the Proposed Solution
Standardized Plan of Care
First is that the patient needs to be assessed during admission and should be continued beyond the hospital. A common strategy for care should be offered according to the analysis and should involve all medical professionals involved (Nielsen et al., 2008). It should also focus on the addition of assessment on inpatient caregivers, home-based clinical nurses, and heart failure clinic nurses which will play an integral part in the flow of information and cooperation of individuals in health care.
Offer Education
Second is the enhanced teaching and education for caregivers to identify the stakeholders which include the family and other caregivers. This process should include verbal, written and visual learning tools to understand the health care needs when the patient leaves the hospital.
Establish Communication Channels
Next is the importance of communication among the patient, his/her family members, and caregivers. The handoff communication is critical in guaranteeing that the clients and medical professionals have a detailed account of the patient’s medical history and cover (Hines et al., 2010). A discharge report is also necessary that entails the client’s health status, health history, baseline details, educational requirements, care provision strategies, and services offered at the hospital. Also, understanding the medication needs and ensuring its availability post-discharge. For patients with a high risk (individuals who are admitted at least two times in the past year for HF, a lack insight about the disease, and low consideration that self-care can be efficiently ...