Coordination team for heart failure: A new model for heart failure care pathway by transfer of knowledge and skills to nurses

Abstract

Background Care pathways are developed to improve the treatment of heart failure (HF), with uncomplete successful because of lack of time and human medical resources. New technology, numerical tools, and cooperation between doctors and nurses could be answers. Objectives (1) get going medication titration, (2) provide a quick answer to early cardiac decompensation, (3) improve in-hospital pathway and discharge coordination, (4) promote home care, and (5) reduce readmission rate. Methods We transfer knowledge and skills from cardiologists to specialized nurses (cooperation work) in the field of chronic HF: medication titration protocol, telemonitoring, and acute HF management. Medical treatment for HF will be optimized at regular intervals, fitting with European guidelines, by HF nurse under the responsibility of a cardiologist as part of a cooperation protocol. At home, symptoms will be monitored by connected scale and tablet transmitting daily weight and answers to targeted questions. Presence of signs of acute HF sets off an immediate evaluation firstly by phone, then by a face-to-face consultation if needed. HF nurse will be in the front line for this early evaluation in order to reduce the delay between symptoms and therapeutic adaptations, and to refer the patient to the most appropriate structure (GP, cardiologist, hospitalisation or home care), without passing through emergency units, while promoting ambulatory care and improving in-hospital pathway. This cooperation protocol aims to be nationally transposed, to all interested heart failure team, in the hospital or in the office. Perspectives With this new model of cooperation, transfer of skills to HF nurses will enhance the quality of care for HF patients, while medical time will be redistributed to complex cases. Inscription to a specific formation for HF nurses will be possible for academic year 2018-2019, and accession to the cooperation protocol is expected for 2019.