Kathleen M. McCauley

The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions.

This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale randomized clinical trial. Subjects were age 65 years or older, admitted from their homes with one of the following diagnosis-related groups: heart failure, angina, myocardial infarction, coronary artery bypass graft surgery, or cardiac valve replacement. The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse (APN) for 4 weeks after discharge. Control subjects received usual care. Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization. There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks. There were no differences in functional status between intervention and control groups for either population. The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative, coordinated discharge planning and home follow-up that includes telephone and home visits by APNs.

Prioritizing the organization and management of intensive care services in the United States: The PrOMIS Conference

Objective:Adult critical care services are a large, expensive part of U.S. health care. The current agenda for response to workforce shortages and rising costs has largely been determined by members of the critical care profession without input from other stakeholders. We sought to elicit the perceived problems and solutions to the delivery of critical care services from a broad set of U.S. stakeholders. Design:A consensus process involving purposive sampling of identified stakeholders, preconference Web-based survey, and 2-day conference. Setting:Participants represented healthcare providers, accreditation and quality-oversight groups, federal sponsoring institutions, healthcare vendors, and institutional and individual payers. Subjects:We identified 39 stakeholders for the field of critical care medicine. Thirty-six (92%) completed the preconference survey and 37 (95%) attended the conference. Interventions:None. Measurements and Main Results:Participants expressed moderate to strong agreement with the concerns identified by the critical care professionals and additionally expressed consternation that the critical care delivery system was fragmented, variable, and not patient-centered. Recommended solutions included regionalizing the adult critical care system into “tiers” defined by explicit triage criteria and professional competencies, achieved through voluntary hospital accreditation, supported through an expanded process of competency certification, and monitored through process and outcome surveillance; implementing mechanisms for improved communication across providers and settings and between providers and patients/families; and conducting market research and a public education campaign regarding critical care’s promises and limitations. Conclusions:This consensus conference confirms that agreement on solutions to complex healthcare delivery problems can be achieved and that problem and solution frames expand with broader stakeholder participation. This process can be used as a model by other specialties to address priority setting in an era of shifting demographics and increasing resource constraints.

A Qualitative Analysis of an Advanced Practice Nurse–Directed Transitional Care Model Intervention

PURPOSE The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs). DESIGN AND METHODS APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences. RESULTS Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond. IMPLICATIONS APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults

AIM This article reports the effects of three evidence-based interventions of varying intensity, each designed to improve outcomes of hospitalized cognitively impaired older adults. MATERIALS & METHODS In this comparative effectiveness study, 202 older adults with cognitive impairment (assessed within 24 h of index hospitalization) were enrolled at one of three hospitals within an academic health system. Each hospital was randomly assigned one of the following interventions: Augmented Standard Care (ASC; lower dose: n = 65), Resource Nurse Care (RNC; medium dose: n = 71) or the Transitional Care Model (TCM; higher dose: n = 66). Since randomization at the patient level was not feasible due to potential contamination, generalized boosted modeling that estimated multigroup propensity score weights was used to balance baseline patient characteristics between groups. Analyses compared the three groups on time with first rehospitalization or death, the number and days of all-cause rehospitalizations per patient and functional status through 6-month postindex hospitalization. RESULTS In total, 25% of the ASC group were rehospitalized or died by day 33 compared with day 58 for the RNC group versus day 83 for the TCM group. The largest differences between the three groups on time to rehospitalization or death were observed early in the Kaplan-Meier curve (at 30 days: ASC = 22% vs RNC = 19% vs TCM = 9%). The TCM group also demonstrated lower mean rehospitalization rates per patient compared with the RNC (p < 0.001) and ASC groups (p = 0.06) at 30 days. At 90-day postindex hospitalization, the TCM group continued to demonstrate lower mean rehospitalization rates per patient only when compared with the ASC group (p = 0.02). No significant group differences in functional status were observed. CONCLUSION Findings suggest that the TCM intervention, compared with interventions of lower intensity, has the potential to decrease costly resource use outcomes in the immediate postindex hospitalization period among cognitively impaired older adults.

A follow-up study of patients with implantable cardioverter defibrillators.

This study involves 381 patients who received an implantable cardioverter defibrillator (ICD) for management of serious ventricular dysrhythmias and were followed for up to 9 years. The device was effective in preventing sudden cardiac death (SCD), with survival rates of 97% at 3 years and 94% at 5 years. Complication rates were low. Two hundred and twenty-five patients received at least one shock; 2.3 shocks per patient year were received. Shocks were categorized as appropriate, indeterminate, or inappropriate. Definitions of these categories and their occurrence are discussed and the characteristics and experiences of these patients are described.

Learning retention in patients receiving midazolam during permanent pacemaker implantation.

This pilot study (N = 20) tested the effects of intravenous midazolam administration on learning retention after pacemaker implantation. Patients were randomized to receive teaching at 1 or 3 hours after the last dose of midazolam. Using a standardized teaching format, one of two study nurses performed the teaching that included incision care, activity restrictions, environmental factors potentially affecting pacemaker function, and follow-up requirements. Learning was evaluated by one of the investigators blinded to teaching time. Subjects in the 1-hour group retained significantly less information than those taught at 3 hours after drug administration. Patients taught later answered similar numbers of questions correctly, whereas there was much more variability in correct responses for the group taught earlier. This article reviews the effects of midazolam on memory and learning as well as provides suggestions for alterations in patient education protocols for patients receiving midazolam for pacemaker implantation. The effect of shortened length of stay on care practices is also discussed.

Assessing social support in patients with cardiac disease.

An increasingly large body of literature demonstrates the positive effects of social support for patients with all illnesses and cardiovascular disease in particular. However, social support is not the same, nor is it equally beneficial in all circumstances. This article reviews key aspects of the social support literature and presents a model for assessing social networks.

Studying nursing interventions in acutely ill, cognitively impaired older adults

OverviewAlthough it increases the risk of poor outcomes and raises the costs of care, cognitive impairment in hospitalized older adults is often neither accurately identified nor well managed. In conducting a two-phase, comparative-effectiveness clinical trial of the effects of three nursing interventions—augmented standard care, resource nurse care, and the transitional care model—on hospitalized older adults with cognitive deficits, a team of researchers encountered several challenges. For example, in assessing potential subjects for the study, they found that nearly half of those assessed had cognitive impairment, yet many family caregivers could not be identified or had no interest in participating in the study. One lesson the researchers learned was that research involving cognitively impaired older adults must actively engage clinicians, patients, and family caregivers, as well as address the complex process of managing postdischarge care.

Effects of alternative interventions among hospitalized, cognitively impaired older adults

AIM Compare within site effects of three interventions designed to enhance outcomes of hospitalized cognitively impaired elders. METHODS Prospective, nonrandomized, confirmatory phased study. In Phase I, 183 patients received one of three interventions: augmented standard care (ASC), resource nurse care (RNC) or Transitional Care Model (TCM). In Phase II, 205 patients received the TCM. RESULTS Time to first rehospitalization or death was longer for the TCM versus ASC group (p = 0.017). Rates for total all-cause rehospitalizations and days were significantly reduced in the TCM versus ASC group (p < 0.001, both). No differences were observed between RNC versus TCM. CONCLUSION Findings suggest the TCM is more effective than ASC. However, potential effects of the RNC relative to the TCM warrant further study.

Heart failure : providing optimal care

Preface Chapter 1: Heart Failure as a National Heath Problem: The Burden of Heart Failure Chapter 2: Heart Failure Guidelines and Disease Management Chapter 3: Managed Care and Heart Failure Chapter 4: Defining Heart Failure: Systolic versus Diastolic Dysfunction, Differential Diagnosis, Initial Testing Chapter 5: Serial Clinical Assessment of the Patient with Heart Failure Chapter 6: Treatment Goals for Heart Failure Patients in Critical Care Chapter 7: Managing Complicated In-patients: Co-morbidities and the Frail Elderly Chapter 8: Transition from Hospital to Home: Interdisciplinary Management Models Chapter 9: Living with Heart Failure: Promoting Adherence, Managing Symptoms, and Optimizing Function Chapter 10: Pharmacologic Management: Achieving Target Doses and Managing Interactions Chapter 11: Continuum of Care: Prevention to End of Life Chapter 12: Surgical Management of Heart Failure Chapter 13: The Management of Heart Failures Electrical Complications: Device Therapy Chapter 14: Moving Ahead with Heart Failure: What does the Future Hold?