State of the Science Quality Improvement mobile apps monitoring CHF reducing readmissions

Chamberlain University

Dr. Bethel

June 14, 2015

Abstract

The condition of heart failure (HF), sometimes also referred to as congestive heart failure (CHF), is recognized as an acute life-threatening disease that extensively affects millions of American citizens annually. The condition of chronic heart failure results when the heart is incapable of sufficiently pumping blood throughout the body to adequately reach the lung and tissues due to the weakening of heart muscles (January et al., 2019). Several conditions overwork the heart, such as coronary artery diseases, as well as hypertension, diabetes, and renal diseases that lead to acute and chronic heart failure in the body systems. It is imperative to prevent, control, and manage this crucial condition as health care expenditures have become a significant focus for the country, especially with readmission rates. The patient must be able to control the earlier stated diseases, diabetes, and obesity in home-based care settings and with their primary healthcare providers. According to Santesmases-Masana et al. (2019), “Primary health care or planned care has been shown to reduce heart failure re-hospitalizations and maintain the patient quality of life.” With this known knowledge, it is important to continue care at home with the partnership of one’s primary care provider to monitor and detect worsening of their condition sooner rather than later with evidence-based treatment practices. There are many evidence-based treatments for chronic heart failure that includes monitoring of vital signs, weight, and diet along with medications. In this paper, chronic heart failure, problem discussion, PICO question, and theoretical framework will be presented.

Problem Discussion

Increase hospital readmission and worsening chronic heart failure complications are correlated to lack of following of a primary care provider directions and inefficient home monitoring of vital signs, weight, diet, energy levels, and breathing patterns by the patient. There are several evidence-based practices and comprehensive guidelines for chronic heart failure treatment with side effects of some medications regarding individual races. For instance, losartan has little to weak impact on African Americans. Furthermore, according to Hadidi et al. (2018), "It has been shown that under prescribing of evidence‐based therapies is associated with worsening heart failure and higher rates of heart failure hospital admissions and mortality." Unfortunately, as the rate of chronic heart failure increases due to the aging population's increase, home monitoring will decline due to mental, physical, and financial instability and lack of support.

Home monitoring is an essential part of patients with chronic heart failure. However, some patients cannot mentally process the importance of taking their vital signs (most importantly, blood pressure) a few times a day and writing it down. With the aging population, dementia may start to set in, and they will forget to take their medication and monitor their blood pressure. They may remember to take their medication but forget to take their vitals, and their blood pressure could already below, which will lead to further complications. The patient may also be physically incapable of using medical equipment if a support person is not present. Other limitations may include financially with the ability to obtain a sphygmomanometer, thermometer, pulse oximeter, or transportation to their primary care provider. Also, their finances may not allow them to purchase healthy foods (more expensive) over non-healthy foods (less expensive) on a routine basis.

Since chronic heart failure requires significant monitoring and treatments, proper health insurance is necessary for continued adequate care. Lack of health coverage will lead to inadequate healthcare due to high costs. This unfortunate event of not having insurance will lead to an increase in emergency room visits and hospital admissions for treatments, interventions, and management. Lack of chronic heart failure monitoring will thus lead to further complications and increase hospital stay. According to Hart and Nutt (2020), "Heart failure (HF) contributes to the highest frequency of 30-day hospital readmissions out of all causes, raising the already significant risk for adverse outcomes and costs." Overall, heart failure is proliferating, with an equally increasing mortality rate. Without proper, patient-specific education with return clarification, new monitoring tools, and technology, hospital readmission will continue to rise. Ongoing, updated, and frequent training is required for patients with chronic heart failure to increase home monitoring and decrease hospitalization.

The aim of decreasing hospital readmission from exacerbation of chronic heart failure will require the collaboration of everyone involved with patient care. Education is the first and most crucial part, starting with the medical team. When emphasizing self-care and chronic heart failure management through effective teaching and communication, combined with follow-ups, hospital readmissions will be minimized (Hart and Nutt, 2020). Ensuring the patient understands and accepts their current condition is a must for them to be compliant at home with the required treatment regimen. Next, make sure they can obtain specific medical equipment at home to assess all their vital signs, most importantly, their blood pressure. Educate them on the normal ranges so abnormal ranges can be reported. Please make sure they can manipulate the equipment and log all their results. Lastly, make sure the patient gets started on the proper diet and able to assess their weight daily. Along with education, multidisciplinary outpatient programs will be very beneficial to the patient, so their knowledge of chronic heart failure and self-care will be sustainable and carried out (Harvey, 2020).

PICO Question and Review of Literature

PICO statement: With the increasing rates of chronic heart failure patient hospital admissions (P), how can hospital readmission be decreased with adequate education and home monitoring (I), after their diagnosis and initial hospitalization (C), during the course of the patient’s condition (O).

For this quality improvement paper, this author used Chamberlain University’s online Library to access many databases such as EBSCO Information Services, CINAHL, Pro-Quest, and Cochrane. Also, the American Heart Association website was used from the Google search engine. Many search terms were used that were relevant to the topic: heart failure, chronic heart failure, stakeholders, insurance management for heart failure, heart failure education, and heart failure monitoring. (See The John Hopkins Question Development Tool in the appendix).

Heart failure is briskly rising in the United States. Still, patients that closely monitor their condition at home leads to cost-effective care and reduce hospital admissions from adequately and timely patient education provided by their provider (Schub & Oji, 2018). The American Heart Association offers a considerable amount of information for heart failure and the importance of patient education. During the initial hospitalization and diagnosis of heart failure, learning should be initiated immediately due to the critical role it plays with chronic heart failure management (January et al., 2019). As the population grows, chronic heart failure increases within the aging population due to deterioration of the heart muscle. A slower progression of the disease can occur with proper self-care (Wonggom et al., 2020). However, Elkhateeb and Salem (2018) did research that showed that the correlation between family support and patient education did not correlate with either hospital readmissions or mortality rates. Luhr et al., (2018) researched was done on elderly education and concluded that the elderly population did not have a more significant outcome of quality of life when given proper training by their primary care provider, compared to those with routine care. However, Hart and Nutt (2020) stated, “As little as one 60-minute, targeted education session with nurses trained in heart failure is effective at improving disease knowledge and self-care and reducing hospital readmissions.”

Quality Change Plan

The theoretical framework that will be used for this quality improvement project is the Situation-Specific Theory of Heart Failure Self-care that was published in 2008, which shows how patients with chronic heart failure care for themselves and manages their condition (Vellone et al., 2019). According to Vellone et al. (2019), “Self-care was defined as a naturalistic decision-making process involving the choice of behaviors that maintain physiologic stability (maintenance) and the response to symptoms when they occur (management).” With this theory, there are three areas of focus on self-care maintenance, symptom perception, and symptom management that help the provider assess the patient’s mental condition (Hart and Nutt, 2020). This theory has been previously used and can be used and applied to this improvement project on chronic heart failure. This is accomplished by describing the patient’s current situation with chronic heart failure, showing how the elements are congruent to each other, and predicting the future/outcomes; however, further research is needed (Vellone et al., 2019).

The condition of chronic heart failure is a concerning factor for many stakeholders. Those that are affected by chronic heart failure along with the patient (primary stakeholder) are their support system, health organizations, insurance companies, primary care providers, and nurses. Besides the patient (with full mental capacity), the support person, nurses, and primary care provider are best to detect changes in early signs of chronic heart failure exacerbation of non-specific symptoms (Harrington, 2019). The primary care provider needs to update and make patient screenings more patient-specific and more closely supervised to ensure understanding and acceptance (Santesmases-Masana et al., 2019). All stakeholders' full knowledge and cooperation with the recommended treatment plan for patients with chronic heart failure are required for a sustainable and effective outcome of limiting hospital readmission. Furthermore, the primary care providers must make sure they are prescribing the right treatment regime for the patient because that could increase their mortality rate.

Guidelines recommend a multidisciplinary approach to HF. Research indicates that various team members to provide knowledge on an individualized basis is beneficial. The use of mobile apps creates significantly improves patient compliance obtained for the management of HF. However, more research is indicated. Interventions are known to reduce rehospitalization rates by 44%, with improved quality of life scores and a reduction in overall costs. The statistical analyses were conducted using GraphPad Prism_7 software (GraphPad Software, La Jolla, CA, USA). Extended variables were given as a calculation pattern ± standard deviation/standard error of the mean and definitive variables as numbers and percentages. Changes amongst clinical or device‐related parameters at the three-time points were evaluated by paired t-test (α  = 0.05). To assess the relationship between traditional clinical settings and mHealth data, the Pearson product-moment interrelationship coefficient (r ) was determined. The measurement certainty of the smart devices compared with precedent amounts was evaluated by appraising the average percentage of a flaw and the mean infinite percentage inaccuracy.

Conclusion

Chronic heart failure is a condition that is ever-increasing in rates globally, with increase hospital re-admissions and mortality rates, especially among the older population. To reduce the advancement of this condition and have better control, collectively, the patient must have sufficient full knowledge of self-care and education on chronic heart failure (Wonggom et al., 2020). Many factors play a vital role in chronic heart failure monitoring and maintenance. The patient must remember to attend all their appointment, monitor their vital signs and weight daily, watch what they eat, and be aware of exacerbation symptoms. By following this alone, the patient’s mortality rate has declined slightly.

References

Chamsi-Pasha, H., & Albar, M. A. (2016). Ethical Dilemmas at the End of Life: Islamic Perspective. Journal of Religion and Health, 56(2), 400–410. doi: 10.1007/s10943-016-0181-3

Elkhateeb, O., & Salem, K. (2018). Patient and caregiver education levels and readmission and mortality rates of congestive heart failure patients. Eastern Mediterranean Health Journal, 24(4), 345–350. doi: 10.26719/2018.24.4.345

Hadidi, S. E., Darweesh, E., Byrne, S., & Bermingham, M. (2018). A tool for assessment of heart failure prescribing quality: A systematic review and meta-analysis. Pharmacoepidemiology and Drug Safety, 27(7), 685–694. doi: 10.1002/pds.4430

Harrington, C. C. (2019). Assessing heart failure in long-term care facilities. Journal of gerontological nursing, 45(7), 18-24.