Application and Promotion of Whole-Process Capacity Management Model for CHF Patients Led by Specialist Nurses in “Heart Failure Center Alliance Unit” ()
1. Introduction
Chronic Heart Failure (CHF) refers to the syndrome of excessive heart load, resulting in heart pumping dysfunction, blood stasis in the veins and lack of blood perfusion in the arteries, causing heart blood circulation disorders, and then leading to a series of clinical symptoms. Chronic heart failure (CHF) with its high morbidity, mortality and readmission rate has become a major public health problem in the world. Capacity overload is a major cause of exacerbation of heart failure. To achieve the optimal volume balance state and maintain “dry body mass” in CHF patients is the key step of treatment. However, the volume status of CHF patients is complex and dynamic, and they lack the capacity of self-volume management, especially in the aspects of daily intake restriction and fluid retention monitoring. However, there is a big gap between the actual work evidence and clinical practice of volume management, and it is not fully implemented based on scientific evidence. As the leading unit of heart failure Center in Jingzhou City, our hospital undertakes 13 surrounding regional cooperative institutions to form a heart failure diagnosis and treatment network system. Therefore, in order to standardize the capacity management behavior, it is imperative to explore and build an effective working mode of CHF capacity management, solve the problem of irregular capacity management, and improve the health outcomes of CHF patients as much as possible [1] . Therefore, this study integrated relevant domestic and foreign guidelines, expert consensus and other evidence on capacity management, to provide a reference for the whole-process capacity management mode of CHF patients led by specialist nurses in clinical practice.
2. Data and Methods
2.1. Search Strategy
2.1.1. Using PIPOST to Establish Evidence-Based Issues
Study subjects: patients with chronic heart failure with cardiac function II to grade; intervention: body quality monitoring/tool application/sodium guidance/drug guidance/follow-up management; professionals: specialist nurses, doctors; study outcome: dry body quality compliance rate/readmission rate/medical care; evidence application: cardiology ward; evidence type: clinical practice guidelines, expert consensus. According to the principle of evidence pyramid, the relevant literature of heart failure volume management was reviewed and analyzed, and the search period was not completed until March 1, 2022. The databases of CNKI (CNKI), Wanfang, VIP (VIP) and Chinese biomedical literature (CBM) were searched; use “heart failure/chronic heart failure/congestive heart failure/cardiac insufficiency/cardiac dysfunction”, “volume management/capacity management/volume overloaded/fluid management/fluid overloaded/fluid retention”, “congestion symptoms/output and input/weight/body edema/body fluid/sodium/diuretic” Search terms in Both Chinese and English, the CNKI (CNKI), Wanfang, VIP (VIP) and Chinese Biomedical Literature (CBM) databases; the PubMed, Embase, Web of Science, and Cochrane Library databases were searched.
2.1.2. Documenting Exclusion Standard
Inclusion criteria for literature on volume management of chronic heart failure: 1) Study subjects for patients with chronic heart failure; 2) literature type for guidelines, consensus, RCT and other interventional studies; 3) intervention content included specific measures for volume management. Literature exclusion criteria: 1) repeatedly published literature; 2) cannot obtain the full text of the literature; 3) literature language is not Chinese or English.
2.2. Obtaining Evidence and Constructing Review Indicators
PIPOST method was adopted to establish evidence-based questions: according to the evidence pyramid principle and search strategy, 2 evidence-based nursing backbones completed literature search in both Chinese and English, and finally included 7 literatures (see Table 1), including 4 guidelines and 3 expert consensus (see Table 2 and Table 3), Summarize on the top 20 pieces of evidence (see Table 4). Focusing on the three key links of capacity assessment, monitoring and management, stakeholders were invited to evaluate each piece of evidence according to the FAME principle, that is, the feasibility, suitability, effectiveness
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Table 1. General characteristics of the included literatures (n = 7).
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Table 2. Quality evaluation results of the included guidelines (n = 4).
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Table 3. Quality evaluation results including expert consensus (n = 3).
Note: (1) Is the source of the opinion clearly marked? (2) Does the opinion come from an influential expert in the field? (3) Is the proposed view to study the relevant person Group interest-centered? (4) Is the conclusion as stated based on the results of the analysis? Is the expression of ideas logical? (5) Do you refer to the other existing literature? (6) Is there any inconsistency between the proposed views and the previous literature?
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Table 4. Summary of evidence on volume management in patients with chronic heart failure.
and clinical significance of evidence (see Table 5). Finally, 11 best pieces of evidence were obtained (see Table 6) and 5 clinical review indicators of cost projects were transformed (see Table 7).
2.3. Baseline Review
Indicator 1: The survey on nurses’ knowledge of capacity management was carried out based on the questionnaire on knowledge, trust and practice developed
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Table 6. Summary of the best evidence for volume management in patients with chronic heart failure.
based on Delphi method, with 51 items in 3 dimensions and 18 nurses; Indicator 2: Patients (or caregivers) were informed of capacity management related education; Indicator 3: Body mass monitoring was carried out and the results were
recorded, standardized procedures were determined, and capacity management plans were implemented. 152 patients were observed on site, department files and mobile medical workstations were consulted and checked; Indicator 4: departments have standardized multidisciplinary team diagnosis and treatment system process and implementation; Indicator 5: Departments have standardized heart failure follow-up system and procedures, 28 medical staff to review department documents. Identify obstacles and construct action strategies (see Table 8).
2.4. Analyzing Obstacles and Constructing Action Strategies
2.4.1. Obstacle Factors 1
There is no capacity management working mechanism
Action strategies: Establish a working mechanism 1) Establish a working mechanism, form an MDT team led by specialist nurses, and clarify work responsibilities and intervention opportunities. 2) Establish a working mode of capacity management, which includes the collection of admission health information, the assessment of in-hospital capacity status, the determination of management objectives, the formulation of management plans, and the follow-up of discharge and out-of-hospital services. 3) From the five dimensions of assessment, measures, health education, management objectives, and result evaluation, the clinical path was developed to run through the whole cycle of heart failure patient management. 4) There are plans to organize the best evidence training and assessment in the department to ensure the training effect.
2.4.2. Obstacle Factors 2
Lack of quantifiable measuring tools for body mass, water and salt measurement, and do not monitor related indicators
Action strategy: indicator monitoring. 1) For body mass monitoring, specialist nurses guide patients to weigh and record at a fixed time and under the same conditions every day; Through the grading table of pitted edema, the patient
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Table 8. List of obstacle factors and action strategies.
was taught to identify the method of early volume abnormality; Set observation items and frequency according to medical goals; According to the patient’s condition, set 24 h fluid intake and outflow amount. 2) For the monitoring of the amount of fluid in and out, guide the patient to use quantitative tools, and compare the conversion table, accurately control the amount of fluid in and out and record it to avoid capacity overload. 3) For sodium salt intake, nutritionists rely on nutritional diagnosis and treatment system, nutritional assessment of patients, start individualized food “traffic light” program, the red light is mainly high salt content of food, prohibited eating; The green light is mainly for food with low salt content, recommended eating; Use visual weight and salt ration bottle, compare salt consumption scale and sodium salt conversion formula, limit sodium salt intake of patients.
2.4.3. Obstacle Factors 3
Lack of special medication guidance for CHF patients
Action strategy: Drug guidance. Clinical pharmacists can determine the rationality of the use of diuretics and the rate of drug target dose compliance through the evaluation of drug monitoring platform and patient signs to ensure drug efficacy. According to the types of special drugs, the corresponding biochemical indicators and signs were monitored. And recommend patients to use timed pill box, timed dose.
2.4.4. Obstacle Factors 4
There is no individualized health education program
Action strategy: individualized health education. 1) Develop self-management guidance manual, regularly carry out special lectures on volume management, and specialist nurses give guidance on self-care ability to tube bed patients twice a week to improve patients’ self-volume management ability. 2) For patients with heart failure with thirst, the degree of thirst was assessed according to visual analog score, and the patients were instructed to relieve thirst by taking ice cubes, chewing sugar-free gum or drinking lemonade.
2.4.5. Obstacle Factors 5
Lack of supervision system for patients returning to their families after discharge
Action strategy: Conduct volume management follow-up. 1) Establish personal capacity management electronic files, and develop follow-up and follow-up management procedures. 2) According to the effect of patient volume management, determine the frequency and form of follow-up. One to one online guidance for those with better management effect; For those with poor compliance, make an appointment in advance and arrange specialist nurses for home visits; For those with poor management effect or symptoms of capacity overload, it is required to go to the local hospital or the heart failure clinic of our hospital in time.
3. Promotion and Application
1) Form a whole-process capacity management model for CHF patients led by specialist nurses, and carry out radiation promotion in Southwest Hubei Union region as the center. At present, it has guided 2 cooperating hospitals to establish grassroots version of heart failure center, and provided standardized capacity management training and guidance to 23 nurses and more than 100 patients. It is planned to complete the promotion and application of the remaining 10 alliance units by 2024.
2) Combined with the “323” key action, joint multi-departments to carry out grassroots activities. Organize 8 special training activities, 88 expert consultations, 6 free screening activities, and select 2 medical cadres to serve at the grassroots level for half a year to solve the problems of early diagnosis, early prevention, early screening and early treatment of CHF patients.
4. Effective Quality Control and Continuous Improvement
1) Set up a quality control team with head nurse and specialist nurses as the core; Set up a special assessment scale to assess the work implementation rate.
2) The specialist indicators are included in the monitoring and management, the specialist nurses make weekly analysis and tracking evaluation, the head nurse summarizes the inspection results every month, analyzes the reasons for several unqualified items, optimizes the strategy in time, and ensures the effective implementation of the program.
5. Effect Evaluation
SPSS25 was used for statistical analysis of the data, and the related indicators of cardiac function, patients’ self-care ability, and the scores of medical staff’s CHF patients’ capacity management knowledge before and after the use of the syndrome were statistically analyzed.
5.1. Patient Level
There were significant differences in LVEF and self-care ability of patients before and after treatment (p < 0.05). In terms of volume management indicators, the dry-body mass compliance rate was increased from 40.1% to 64.4%, while the read hospital admission rate and BNP value had no significant difference (p > 0.05) (see Tables 9-11).
5.2. Hospital Level
1) The scores of doctors’ and nurses’ attitude towards volume management increased from 10 to 18, knowledge from 32 to 55, and behavior from 9 to 16 (all p < 0.05) (see Table 12).
2) Re-examination of the review indicators after the application of evidence: 174 patients admitted from June to October 2021 were used as the trial group for the second round of baseline review, and the results showed that all 5 indicators were improved (see Figure 1).
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Table 9. Comparison of cardiac function related indicators in CHF patients before and after the application of evidence.
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Table 10. Comparison of indicators of volume management in CHF patients before and after evidence application.
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Table 11. Comparison of self-care ability in CHF patients before and after evidence application.
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Table 12. Comparison of knowledge scores of CHF patients before and after evidence application.
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Figure 1. Post-application review of evidence.
5.3. Social Dimension
Formulation and practice of volume management plan for patients with chronic heart failure.
1) As a unit of the heart failure Center alliance, promote the capacity management program to the radiated medical institutions, and update the concept through training.
2) To carry out special training for hospitals in the Alliance area, organize provincial and municipal continuing education training courses, expert consultation, free clinic screening activities, help cooperative hospitals to establish heart failure centers, send medical backbone grass-roots services, and expand the use of syndrome nursing.
6. Discussion
6.1. The Whole-Course Volume Management Mode of CHF Patients Led by Specialized Nurses Can Improve Patient Cardiac Function
Cardiac ultrasound examination can judge the functions of the heart, LVEF value is the reflection of cardiac systolic function, LVEF normal value in 50% - 70%, the increase of LVEF value indicates that the heart failure symptoms are improved [8] . After the application of evidence, the difference of LVEF was lower than before the application of evidence, this study made patients realize the importance of volume management by correcting previous management errors through face-to-face demonstration, one-to-one guidance, providing management tools to better master the volume management method, more accurately assess their own fluid retention, reduce the risk of volume overload, and have a certain positive impact on their heart contraction function [9] . BNP is important for the diagnosis of heart failure, differentiation of cardiac function, and prognosis, and is positively correlated with the severity of heart failure [10] . The results of this study showed that the difference in BNP between the two groups before and after the evidence application was not significant, which contradicted the study results of Ni Jian [11] and Chen Hua [12] . The analysis reason may be that the intervention time in this study was one month, which should be extended to 3 months to further observe the changes of plasma BNP concentration in CHF patients.
6.2. The Whole-Process Volume Management Mode of CHF Patients Led by Specialized Nurses Can Effectively Reduce the Patient Readmission Rate
Hospital-discharge readmission rates in elderly patients with chronic HF remained high, with up to 20% within 1 month. The readmission rate within 3 months after discharge can be as high as 30%, and the risk of all-cause death is significantly increased by 4 to 6 times [13] compared with patients not hospitalized with heart failure. During rehospitalization, the cardiac function will show progressive decline, and the congestion symptoms will be more serious. The results of the study readmission rate showed a significant difference between the two groups in March after discharge (p < 0.05), consistent with the results of Lin Li [14] and Jiang Y [15] et al., patients with this model could establish and maintain volume management behavior, thus exerting the significant effect of volume management in reducing the readmission rate of patients with heart failure.
6.3. The Whole-Process Volume Management Mode of CHF Patients Led by Specialized Nurses Can Improve the Dry Body Quality Compliance Rate of Patients
The main reason for frequent hospitalization in patients with heart failure is volume overload, and dry body mass refers to the body mass of patients with heart failure without the symptoms and signs of congestion. In this study, the body mass on the day of discharge was used as the reference standard of dry body mass [16] . In the control group of this study, most of the patients were obviously volume overload, and those who failed to meet the standard after discharge before evidence application.
6.4. The Whole-Process Volume Management Mode of CHF Patients Led by Specialized Nurses Can Improve the Quality of Life of Patients
Patients with chronic heart failure generally have fatigue, fatigue dyspnea and edema and other physical symptoms, some patients. It will also be accompanied by psychological symptoms such as anxiety, depression and other psychological symptoms, which significantly reduce the quality of life of patients [17] , and low quality of life is associated with the number of readmissions of patients with chronic HF, which will significantly increase the risk of death, which can be used to predict the prognosis of patients [18] . The higher the MLHFQ score represents the worse quality of life, the score after the evidence application was lower than before the evidence application and the difference was significant, and the representative pattern has a significant effect on the improvement of short-term quality of life of patients in the intervention group.
7. Summary of the Effect
7.1. For Patients
The evidence-based capacity management scheme for CHF patients can significantly improve the self-care ability of patients and their caregivers, reduce the risk of capacity overload, improve the quality of life of patients, and promote the post-hospital rehabilitation effect of CHF patients.
7.2. For Medical Service Providers
Improve the cognition, teamwork spirit, evidence-based ability and scientific research quality of medical staff on capacity management of CHF patients.
7.3. For Hospitals
1) Focus on clinical hot spots and difficult problems, and apply the latest and best evidence to chronic heart failure volume management; 2) The outcome indicators involved in improving the volume management behavior and health outcomes focus on the current national cardiovascular quality control index 1 and nursing quality control index 2; 3) The concept radiates from the hospital to the outside, and is promoted to 13 medical institutions in northwest Hubei, forming a certain influence at the city and county level.
7.4. Social Effect
1) Passed the certification of “Heart Failure Center” in 2021, actively promoted the linkage up and down, graded diagnosis and treatment, and established the CHF capacity management network medical link system. The capacity management has covered 13 prefecty-level network medical link systems such as Songzi, Jianli, public security, Shishou, a number of community service stations and township health centers around the region; 2) Since June 2021, a total of more than 879 health records for patients with heart failure have been established to conduct standardized capacity management of them, and improve patients’ cognition and self-care ability through four aspects: body quality monitoring, drug intervention, health education and follow-up; Among them, 237 patients were revisited; Two-way referral of 35 patients; And remote consultations 26; 3) Carried out 8 “Heart failure network regional cooperative hospital training meetings”; Held 2 provincial and municipal continuing education training courses “New Progress in Heart failure Diagnosis and Treatment Study Class 06-2022-03-01-008” and municipal continuing education project “New Progress in Cardiovascular Disease basic Hospital Promotion Study Class 2022-03-01-024”; On-site expert consultation, free screening activities 6; 4) Selected key doctors and nurses to conduct center construction and capacity management program guidance training for cooperative hospitals, and 2 cooperative units have passed the certification unit of grassroots heart failure center.
8. Summary
This study constructed a full-process capacity management model for CHF patients guided by specialist nurses. The model was then applied and promoted in the “heart failure center alliance unit” to improve the capacity management ability of medical staff for CHF patients and enhance the self-management ability of CHF patients. This led to improvements in capacity management behavior and health outcomes, effectively reducing the hospitalization and mortality rates of CHF in the region. Due to the dynamic nature of the evidence, the team will continue to pay attention to the update of the evidence, and the next step will be to expand the MDT team with multidisciplinary collaboration, strengthen regional collaboration, promote the implementation of best practices in combination with clinical scenarios, promote the application scope of the model, and truly realize the linkage between the upper and lower levels based on the alliance center, and build a bridge for capacity management.