Education of patients and staff improves outcomes

What do you do when you find that more than 20% of your new admissions are for cardiac-related reasons and about 33% of your patients have cardiac disease, even if it wasn’t the reason for admission? If you are the staff at Visiting Nurse Association of Central New York (VNA) in Syracuse, you put together a special team of employees who work only with cardiac care patients and call it Heart Smart.

The Heart Smart program increased the agency’s exposure as an expert in home care for heart patients and also decreased hospital re-admissions for congestive heart failure patients, says Mary P. Hussain, RN, MSRN, CNS, clinical nurse specialist for Heart Smart. Staff members on the Heart Smart team undergo intensive training related to cardiac disease to help them become experts on their patients’ care, she says. Comprehensive patient education is used to teach patients to recognize signs that indicate changes in their condition and take steps to improve their condition, she says.

Heart Smart patients see the same staff members each visit except in cases of staff vacation or illness, says. "This continuity improves the effectiveness of patient teaching because the nurse knows what has been taught," she points out. The continuity also strengthens the relationship between the nurses and the patients and family members, Hussain says. If a staff member is unavailable, another nurse who is member of the cardiac team makes the visit, she adds.

Staff continuity improves compliance

The strong relationship improves a patients’ desire to follow instructions on daily weight monitoring and other activities to control and monitor their condition. It also results in the patients’ being less likely to go to the physicians’ offices or emergency departments for changes that might be controlled at home, Hussain points out.

"Our patients are comfortable calling us to report changes in their condition," she explains. For example, each patient monitors weight on a daily basis and is given parameters for weight control, she says. If a patient’s weight exceeds those parameters, the patient knows to call the nurse, she adds. This call gives the home health nurse a chance to talk with the patient to determine what might have caused the weight gain, and to make a home visit to assess the patient. "Our immediate intervention can usually prevent a hospital admission," she adds.

The Heart Smart program focuses upon patient education to keep patients at home and out of the hospital. "We follow a clinical path that includes skilled nursing, physical therapy, and nutritional evaluations as our approach to improving the patient’s quality of life," says Diane Nanno, RN, BSN, clinical nurse manager for VNA. "We’ve also developed a teaching manual that not only explains how to monitor with pulse oximetry and daily weight, but also gives the patients and nurses a place to write the information, including vital signs taken at visits, as it is obtained," she says. This informal medical record serves as an excellent method of communication for a nurse or therapist who might fill in for a staff member on vacation as well as for family members, she adds.

A nurse visits a new Heart Smart patient three times in the first week of admission. The nurse next makes two visits for two weeks, and then weekly visits up to six weeks, reports Hussain. "Between visits we check on patients by telephone and we add visits as needed," she says.

Because the program relies heavily on education, a patient must be teachable or must have a teachable in-home caregiver to be eligible for Heart Smart, says Hussain.

First year brings positive results

Although the program is just over one year old, there have been some positive results in terms of recognition for the agency, says Amor Bango, RN, BSN, director of clinical operations. "In February 2004, we were asked to provide the home care component for patients of a local hospital that developed a clinic for heart patients receiving nesiritide, an intravenous medication to treat symptoms of patients suffering advanced heart failure," she says.

The patients receive the infusion at the hospital clinic, then Bango’s staff are responsible for patient education, monitoring any side effects, and assessing the patient’s condition, she explains. "We would never have been contacted if we had not developed the reputation as an agency that specialized in care of cardiac patients," she adds.

"I’ve also noticed that communications between cardiologists and our nurses are greatly improved because there is a new level of respect for these nurses who have become experts on heart patients," says Hussain. And the fact that there is one nurse who knows the patient very well is another advantage for the physician, she adds.

The best thing about the program is the fact that focusing on this group of patients was relatively easy, says Hussain. She points out, "We were already providing excellent care. This program just enhances that care and gives the nurses a chance to increase their knowledge and expertise."